Confined Space Assessment Study Form

Information

  • Assessment Study Conducted By:

  • Location of Identified Space:

  • Time of Study:

  • Definition : An enclosed or partially enclosed space that is not intended or designed for human occupancy, within which there is a risk of:
    • Oxygen concentration less than the safe level;
    • Airborne contaminant that may cause impairment, loss of consciousness or asphyxiation;
    • A presence of a gas or substance that displaces oxygen
    • Flammable airborne contaminant that may cause injury from a fire or explosion;
    • Engulfment in a stored free-flowing solid or rising level of liquid that may cause suffocation or drowning.
    It is important to note that a confined does not necessarily have to be small and “confined” it simply has to be “not designed for continuous human occupancy”.

QUESTIONS

  • 1. Is the space enclosed or partially enclosed?

  • 1. Floors- clean and free of dirt or other dangers

  • 2. Is the space intended or designed primarily for other use other than human occupancy? Would you put your desk there to do work

  • 3. Is the place being entered a limited or restricted means for entering and exiting the space.

  • 4. May the oxygen concentration levels be outside the safe oxygen level range?

  • 5. May the atmospheric contaminants cause impairment , loss of consciousness or asphyxiation?

  • 6. Are there atmospheric contaminants which may cause injury from fire or explosion?

  • 7. Is there a possibility of free-flowing solid or a rising liquid that may cause suffocation or drowning by engulfment?

  • 8. Is there a possible presence of a gas which displaces oxygen [such as SF6]

  • 9. Is the access to the confined spaces is via a ladder or perhaps a spiral staircase or through a hatch or small opening.

Other Details:

  • Other item- If there is a Yes answer to any of the above questions, then it is a “Confined Space”s

Report by Inspector:

  • Signature:

  • Assessor:

  • Select date

  • Signature of Department Manager:

  • Name of Department Manager

  • Time Accepted:

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