Pre-Task: Confined Space Checklist

• Conducted on

  Date

• Prepared by

• Job Number

• Location
  Address

Confined Space Details

• Project / Site Name

• A confined space means an enclosed or partially enclosed space that is not designed for continuous occupancy. A confined space requires a permit (in relevant jurisdictions) if a space may also: contain a hazardous atmosphere; contain material that has the potential to engulf an entrant; has walls that converge inward or floors that slope downward and taper into a smaller area which could trap or asphyxiate an entrant; or contains any other recognized safety or health hazard, such as unguarded machinery, exposed live wires, or heat stress.

• Is a permit required for this space?

  Yes

  No

• Is a permit currently valid for the confined space?

  Yes

  No

• Permit issued to

• Date and time of entry

  Date

• Description of work

• Location
  Address

• Specific Location on site

Preparation

• Space ventilated to full extent possible?

  Yes

  No

  N/A

• All people involved have completed confined space training?

  Yes

  No

  N/A

• Has Lock Out Tag Out been verbally confirmed with Authorized Corteva Personnel?

  Yes

  No

  N/A

• Has placement of all LOTO keys into buddy box been verified?

  Yes

  No

  N/A

• Has Corteva lock placement on white labeled slot on buddy box been verified?

  Yes

  No

  N/A

• Has the air monitoring been performed to clear the entry space?

  Yes

  No

  N/A

• Have all entrants reviewed and signed the Confined Space permit?

  Yes

  No

  N/A

• Communications plan defined and understood by all involved?

  Yes

  No

  N/A

Team Sign Off

• Have all relevant personnel participated in pre-entry briefing?

  Yes

  No

  N/A

• Confined Space Entrants: We (I) have verified LOTO procedures and air clearance with the Corteva authorized person.

Confined Space Entrant

• Name and Signature (entrant to sign)

  Sign

• Confined Space Entry Supervisor: I have complete properly evaluated this confined space and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the entry and are adequately trained to perform this task.

Confined Space Entry Supervisor

• Name and Signature (supervisor to sign)

  Sign