Goodfellow Non-Permit Confined Space Hazard Assessment

• Project

• Job #

• Date and Time Issued

  Date

• Location of Confined Space and work to be accomplished

Pre-Entry Atmospheric Testing

• Time

  Date

• Oxygen % Allowable: 19.5% - 23.5%

• LEL % Allowable: 0 - 10%

• CO (ppm) Allowable: 0 - 35 ppm

• H2S (ppm) Allowable: 0 - 10 ppm

• Test equipment used

• Calibration Date

  Date

Entry Personnel and Attendants

• Entry Personnel

Person

• Add signature

  Sign

• Attendant

Person

• Add signature

  Sign

• Communications to be Used During Entry:

  Select Voice Visual Radio

  • Voice
  • Visual
  • Radio

• Rescue procedures

The following conditions have been evaluated for safe entry

• No Hazardous Chemicals

• No Toxic Fumes, Gases, or Vapors

• No Nearby Hazardous Operations

• No CO from Heaters, Generators, etc.

• No Mechanical Hazards

• No Electrical Hazards

• Adequate Lighting

• No Heat or Cold Extremes

• No Fire Hazards

• No Engulfment Hazards

NON-PERMIT CONFINED SPACE CLASSIFICATION: For this space to be classified as Non-Permit Required Confined Space, the supervisor must sign the following statement:

• I have reviewed the above work area and have determined that the space is free of any recognized hazards, which would define this space to be a permit required confined space.

  Sign

• Select date

  Date

Periodic Atmospheric Testing During Entry

• Enter time of testing

Time

• Time

  Date

• Oxygen % Allowable: 19.5% - 23.5%

• LEL % Allowable: 0 - 10%

• CO (ppm) Allowable: 0 - 35 ppm

• H2S (ppm) Allowable: 0 - 10 ppm