Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • SPACE / EQUIPMENT IDENTIFIER:

STEP ONE: If all three are checked, it is a "Confined Space"

  • Is space large enough for an EE to bodily enter and perform assigned work?

  • Are there limited or restricted means of entry or exit?

  • Is space NOT designed for continuous occupancy?

STEP TWO: If ANY following hazard is present, it is a "PERMIT-REQUIRED Confined Space"

  • Contains or has the potential to contain a hazardous atmosphere?

  • Oxygen Deficiency (<19%)?

  • Flammable Materials?

  • Toxic Substances?

  • OTHER Hazard? If Yes, List.

  • Monitoring Equipment Required? If Yes, List.

  • Ventilating Equipment Required? If Yes, List.

  • Communication Equipment Required? If Yes, List.

  • Is a Rescue Team on site?

  • Is an Off-Site Rescue Team on Standby? If Yes, list who & where.

  • Is a retrieval system required and/or available?

  • Are wristlets required and/or available?

  • Is a Tripod & safety harness required and/or available?

  • Are Communication Devices Required and/or available?

  • Is an Emergency Call list available?

  • OTHER requirement not identified? If Yes, List.

  • Contains a material that has potential to engulf an entrant?

  • Is there a potential for Flowable Materials?

  • Are Hard Hats required and/or need to be available?

  • Is Eye Protection required and/or needs to be available? If REQUIRED, list type(s).

  • Is Hearing Protection required and/ or needs to be available? If REQUIRED, list type(s).

  • Are Gloves required and/or needs to be available? IF REQUIRED, list type(s).

  • Is special Safety Footwear required and/or needs to be available? If REQUIRED, list type(s).

  • Is Respiratory Protection required and/or needs to be available? If REQUIRED, list type(s).

  • Is Special Clothing required and/or needs to be available? If REQUIRED, list type(s).

  • Is the space so configured that it poses a hazard?<br>-inwardly converging walls?<br>-floor which slopes downward and tapers to a smaller cross-section?

  • Are there downward sloping floors?

  • Are there inwardly converging walls?

  • Is Special Lighting required and/or needs to available? If REQUIRED, list type(s).

  • Are Explosion-Proof or Spark-Proof Tools required and/or needs to be available? If REQUIRED, list type(s).

  • Are GFCI's required?

  • Is Special Electrical Personal Protective Equipment required and/or needs to be available? If REQUIRED, list type(s).

  • Are Ladders required and/or needs to be available? If REQUIRED, list type(s).

  • Are MSDS (Material Safety Data Sheets) required and/or needs to available?

  • OTHER requirement NOT listed:

  • Is cleaning or purging required?

  • Is Ventilation required and/or needs to be available? If REQUIRED, list type(s).

  • Is Isolation and/or Block & Bleed required?

  • Is Testing and/or Monitoring - Oxygen (19.5 - 23.5%) required?

  • Is Testing and/or Monitoring - Flammable (<10% LEL) required?

  • Is Testing and/or Monitoring - Toxics (<PEL) required?

  • Review of applicable MSDS (Material Safety Data Sheets) required?

  • Is a HOT WORK PERMIT required?

  • OTHER requirement NOT listed?

  • Contains any other recognized serious safety or health hazard? (not listed here) If Yes, list.

  • Are there Mechanical Hazards? If Yes, list.

  • Are there Electrical Hazards? If Yes, list.

  • Are there Wet/Slippery Conditions? If Yes, Explain.

  • Are there Heat and/or Cold Safety Concerns? If Yes, Explain.

  • Is there a potential for Reduced Visibility? If Yes, Explain.

  • Is there a Noise Concern? If Yes, Explain.

  • OTHER Hazardous Concern NOT listed?

COMMENTS / ADDITIONAL INFORMATION

  • Photograph of Space #1 OPTIONAL

  • Photograph of Space #2 OPTIONAL

  • Photograph of Space #3 OPTIONAL

  • Photograph of Space #4 OPTIONAL

  • SPECIAL REQUIREMENTS FOR NON-PERMITTED SPACES:

Entrants and Attendants

  • Entrant(s)?

  • Entrant(s) Signature

  • Attendant?

  • Attendant's Signature

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