Information
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Audit Title
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Document No.
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Conducted on
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Prepared by
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Job Number
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Location
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Job Name
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Personnel
Confined Space Details
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Project / Site Name
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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.
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Is a permit required for this space?
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Is a permit currently valid for the confined space?
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Permit issued to
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Date and time of entry
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Description of work
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Location
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Specific Location on site
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Identify potential hazards of this confined space? (select all that apply)
- Flammable Atmosphere
- Corrosive
- Reactive
- Toxic
- High Temperature
- Low Temperature
- Engulfment
- Other Hazards
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Describe other hazard(s)
Preparation
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Space ventilated to full extent possible?
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All people involved have completed confined space training?
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Vehicles and plants removed from confined space to reduce fume hazard? If not, have precautions been put in place?
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Correct confined space signage in place?
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Space lighting in place and appropriate?
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Access (both entry and exit) points have been identified and are clear of hazards for use?
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Communications plan defined and understood by all involved?
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Select methods of communication to be adopted (select all that apply)
- Cell phone
- Two-way radio
- Rope signals
- Sounds
- Verbal communication
- Hand signals
- Other
Air Monitoring
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Does the air of this confined space require monitoring?
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Is the air of the confined space being continuously monitored? (as required)
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Log air sample results
Air Sample
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Time of sample
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Sample result
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Is this sample within acceptable parameters? Should confined space work proceed?
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Has air monitoring equipment been calibrated?
Safety Equipment & PPE
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Select equipment to be used in this confined space entry
- Warning signs, barricades
- Barricade tape, cones
- Ventilation fan or blower
- Fire equipment in place
- GFCI'S in place
- Lighting (rated for hazardous locations)
- Grounding and/or bonding
- Ladder
- Other
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Describe other equipment
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Select PPE to be used in this confined space entry
- Airline respirator
- Self-contained breathing apparatus
- Other respirator
- Gloves
- Rain gear
- Boots
- Hearing protection
- Safety glasses
- Fall protection/arresting equipment
- Chemical splash goggles
- Other
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Describe other PPE
Rescue & Emergency Plan
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Emergency evacuation and rescue plan is complete, in place and understood by all employees?
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Emergency Number
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Location of phone or radio
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Emergency actions to be taken
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Potential emergency situations
Team Sign Off
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Have all relevant personnel participated in pre-entry briefing?
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Confined Space Entrants: We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment and communication methods. I have been formally trained in confined space entry.
Confined Space Entrant
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Name and Signature (entrant to sign)
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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. I have been formally trained in confined space entry.
Confined Space Entry Supervisor
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Name and Signature (supervisor to sign)