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?
Is a permit currently valid for the confined space?
Permit issued to
Description of work
Specific Location on site
- Flammable Atmosphere
- High Temperature
- Low Temperature
- Other Hazards
Describe other hazard(s)
Space ventilated to full extent possible?
All people involved have completed confined space training?
Vehicles and plants removed from confined space to reduce fume hazard? If not, have precautions been put in place?
Correct confined space signage in place?
Space lighting in place and appropriate?
Access (both entry and exit) points have been identified and are clear of hazards for use?
Communications plan defined and understood by all involved?
- Cell phone
- Two-way radio
- Rope signals
- Verbal communication
- Hand signals
Does the air of this confined space require monitoring?
Is the air of the confined space being continuously monitored? (as required)
Is this sample within acceptable parameters? Should confined space work proceed?
Has air monitoring equipment been calibrated?
- 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
Describe other equipment
- Airline respirator
- Self-contained breathing apparatus
- Other respirator
- Rain gear
- Hearing protection
- Safety glasses
- Fall protection/arresting equipment
- Chemical splash goggles
Describe other PPE
Emergency evacuation and rescue plan is complete, in place and understood by all employees?
Location of phone or radio
Emergency actions to be taken
Potential emergency situations
Have all relevant personnel participated in pre-entry briefing?