Non Permit Required Confined Space Checklist

• Conducted on

• Prepared by

• Location

• Date & Time

  Date

• Job Site

Evaluate if new hazards will be created by the planned work (check if true statement)

• No activities will be conducted that could create a hazard inside the confined space (such as welding or breaking a line)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No conditions exist around this space that could adversely affect anyone within the space

  Yes

  No

  N/A

Verify that no atmospheric hazards exist (check if true statement)

• Air sampling conducted on the top, middle and bottom of the space are within the last 12 months

  Yes

  No

  N/A

Air sampling conducted on the top, middle, and bottom of the space are within the following parameters:

• Oxygen - between 19.5% and 23.5%

  Yes

  No

  N/A

• LEL or LFL less than 10%

  Yes

  No

  N/A

• Hydrogen sulfide less than 10 ppm

  Yes

  No

  N/A

• Carbon monoxide less than 35 ppm

  Yes

  No

  N/A

• Previous assessments have failed to identify hazards within this space. Verify that no new

  Yes

  No

  N/A

Previous assessments have failed to identify hazards within the space. Verify that no new hazards have been introduced in the space. The space does not contain:

• - a material that could engulf an entrant (such as water)

  Yes

  No

  N/A

• - exposed/unprotected mechanical equipment

  Yes

  No

  N/A

• - exposed/unprotected electrical conductors

  Yes

  No

  N/A

• - exposed/unprotected fall hazards

  Yes

  No

  N/A

• - extreme high or low temperature (greater than 110 F or less than 25 F)

  Yes

  No

  N/A

• - friable asbestos containing material

  Yes

  No

  N/A

• Checklist completed by:

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