Non Permit-Required Confined Space Checklist

• Site conducted
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• Conducted on

  Date

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• Prior to entering a non-permit required confined space, the space must be evaluated to performed in the space. The following checklist assists in this evaluation.

Evaluate if new hazards will be created by the planned work

• No activities will be conducted that could create a hazard inside the confined space

  Yes

  No

  N/A

• No chemicals will be brought into the space that could create a hazard (such as solvents, toxic gasses, or adhesives)

  Yes

  No

  N/A

• No conditions exist around this space that could adversely affect anyone within the work area or those outside or near it

  Yes

  No

  N/A

• Air monitor has been calibrated within the last 12 months and is checked regularly

  Yes

  No

  N/A

Verify that no atmospheric hazards exist and ensure these gasses are at safe working levels:

• Oxygen

  Yes

  No

  N/A

• Hydrogen sulfide

  Yes

  No

  N/A

• Carbon monoxide

  Yes

  No

  N/A

• Lower Explosive Limit (LEL) or Lower Flammable Limit (LFL)

  Yes

  No

  N/A

The space does not contain:

• Materials that could engulf an entrant (such as water)

  Yes

  No

  N/A

• Exposed, unprotected, or unmaintained mechanical equipment

  Yes

  No

  N/A

• Exposed, unprotected, or stray electrical conductors

  Yes

  No

  N/A

• Unmanaged fall hazards

  Yes

  No

  N/A

• Asbestos or asbestos-generating materials

  Yes

  No

  N/A

Completion

• Comments and Recommendations

• Prepared By

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