• I. CONFINE SPACE

  • 1. Area was NOT designed for continuous human occupancy.

  • 2. Area can be bodily entered and assigned work performed.

  • 3. Area has limited and/or restricted means of access and egress.

  • Add photograph(s) that better describes of what was observed.

  • II. PERMIT REQUIRED CONFINED SPACE DETERMINATION

  • 4. Does the space have or have the potential for a hazardous atmosphere?

  • 4 (i). If yes, please mark the hazard(s) below:

  • 4(i)(a). Oxygen Deficiency

  • 4(i)(b). Oxygen Enrichment

  • 4(i)(c). Explosive Gas/Vapor

  • 4(i)(d). Explosive Dust

  • 4(i)(e). Hydrogen Sulfide

  • 4(i)(f). Carbon Monoxide

  • 4(i)(g). Chlorine

  • 4(i)(h). Other

  • Please specify:

  • 5. Does the space have the potential to engulf the entrant?

  • 5(a). Water

  • 5(b). Sand

  • 5(c). Soil

  • 5(d). Gravel/Loose Rock

  • 5(e). Sewage

  • 5(f). Oil

  • 5(g). Other

  • Specify other potential of engulfment
  • 6. Does the space have the potential to entrap the entrant?

  • 7. Is there a potential for any other serious safety and health hazard?

  • 7(a). Electrical

  • 7(b). Moving Parts

  • 7(c). Slips and Trips

  • 7(d). Falling (more than 5 ft)

  • 7(e). Extreme Heat (above 100 degrees F)

  • 7(f). Cold

  • 7(g). Skin and Eye Irritant

  • 7(h). Noise

  • 7(i). Chemicals

  • Specify other potential Safety and Health Hazards.
  • Add photographs Add photograph(s) that better describes of what was observed.

  • 9. Will ventilation be required for the space?

  • 10. Will the entrant need to detach from the lifeline requiring rescue to be on site?

  • III. ALTERNATE ENTRY PROCEDURE DETERMINATION

  • 11. If parts 5‐7 of Section II were marked YES, then alternate entry procedures are NOT allowed for the space.

  • 12. Is the only hazard an actual or potential hazardous atmosphere?

  • 12(a). If yes, will ventilation alone maintain safe conditions?

  • IV. FINAL DETERMINATION

  • Check All that Apply

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