Information
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Audit Title
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Location
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Select date
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Prepared by
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Space Location:
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Space Description:
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Add media
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I. CONFINE SPACE
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1. Area was NOT designed for continuous human occupancy.
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2. Area can be bodily entered and assigned work performed.
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3. Area has limited and/or restricted means of access and egress.
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Add photograph(s) that better describes of what was observed.
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II. PERMIT REQUIRED CONFINED SPACE DETERMINATION
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4. Does the space have or have the potential for a hazardous atmosphere?
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4 (i). If yes, please mark the hazard(s) below:
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4(i)(a). Oxygen Deficiency
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4(i)(b). Oxygen Enrichment
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4(i)(c). Explosive Gas/Vapor
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4(i)(d). Explosive Dust
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4(i)(e). Hydrogen Sulfide
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4(i)(f). Carbon Monoxide
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4(i)(g). Chlorine
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4(i)(h). Other
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Please specify:
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5. Does the space have the potential to engulf the entrant?
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5(a). Water
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5(b). Sand
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5(c). Soil
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5(d). Gravel/Loose Rock
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5(e). Sewage
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5(f). Oil
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5(g). Other
Specify other potential of engulfment
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6. Does the space have the potential to entrap the entrant?
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7. Is there a potential for any other serious safety and health hazard?
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7(a). Electrical
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7(b). Moving Parts
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7(c). Slips and Trips
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7(d). Falling (more than 5 ft)
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7(e). Extreme Heat (above 100 degrees F)
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7(f). Cold
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7(g). Skin and Eye Irritant
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7(h). Noise
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7(i). Chemicals
Specify other potential Safety and Health Hazards.
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Add photographs Add photograph(s) that better describes of what was observed.
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9. Will ventilation be required for the space?
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10. Will the entrant need to detach from the lifeline requiring rescue to be on site?
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III. ALTERNATE ENTRY PROCEDURE DETERMINATION
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11. If parts 5‐7 of Section II were marked YES, then alternate entry procedures are NOT allowed for the space.
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12. Is the only hazard an actual or potential hazardous atmosphere?
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12(a). If yes, will ventilation alone maintain safe conditions?
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IV. FINAL DETERMINATION
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Check All that Apply
