RHC Confined Space Assessment Form

• Audit Title

• Location
  Address

• Select date

  Date

• Prepared by

• Space Location:

• Space Description:

• Add media

  Media

1.Criteria for a Confined Space

• 1(a). Is this an area that was not designed for continuous human occupancy.

  Yes

  No

• It is a confined space

• 2(a). Area can be bodily entered and assigned work performed.

  Yes

  No

• It is a confined space

• 3(a). Area has limited and/or restricted means of access and egress.

  Yes

  No

• It is a confined space

2. Classification of the Confined Space

• 2. (a) Does the space have or reasonably have the potential for a hazardous atmosphere?

  Yes

  No

• 4 (i). If yes it is a Class "A" Confined Space, please mark the hazard(s) below:

• Oxygen Deficiency

• Oxygen Enrichment

• Explosive Gas/Vapor

• Explosive Dust

• Hydrogen Sulfide

• 4(i)(f). Carbon Monoxide

• 2(b) Does the space have the potential to engulf the entrant?

  Yes

  No

• If yes it is a Class "A" Confined Space, please mark the hazard(s) below:

• Water

• Sand

• Soil

• Gravel/Loose Rock

• Sewage

• Oil

• Other

• Describe hazard

• 2. (c) Does the space have the potential to entrap the entrant?

  Yes

  No

• Describe the risk

• 2. (d) Is there a reasonable potential for any other serious safety and health hazard?

  Yes

  No

• Electrical

• Moving Parts

• Slips and Trips

• Falling (more than 5 ft)

• Extreme Heat (above 100 degrees F)

• Cold

• Noise

• Chemicals

• 2. (e) Is the entry or is there access by any part of the confined space restricted by 2 feet or less

  Yes

  No

• Describe the condition

• 2. (f) Is the entry or access in the confined space larger than 2 feet but less than 4 feet?

  Yes

  No

• FINAL DETERMINATION

• Was "yes" answered to any of questions in section 2 (a) thru 2(d) "Criteria for a Confined Space"?

  Yes

  No

• This is a class "A" Confined Space

• Is a top entry required to access the space?

  Yes

  No

• Entry is not allowed by RHC Staff a contractor must be scheduled to complete work in confined space

• What was the response to question 2. (e)?

  Yes

  No

• This is a Class "B" Confined Space

• What was the response to question 2. (f)?

  Yes

  No

• This is a Class"C" Confined Space

Non IDLH Hazards and Control Measures

• Sharps/cuts/punctures/abrasion

• Description

• Control Measure

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• Noise

• Description

• Control Measure

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  Media

• Pressurized system/compressed gas

• Description

• Control Measure

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  Media

• Obstruction(s)

• Control Measure

• Description

• Add media

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• Fire / Explosion / Flammable

• Description

• Control Measure

• Burns

• Description

• Control Measure

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  Media

• Dusts/ Fumes/ Vapors

• Description

• Control Measure

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  Media

• Asbestos

• Description

• Control Measure

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  Media

• Poor visibility

• Description

• Control Measure

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  Media

• Working Alone

• Description

• Control Measure

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• Hearing

• Control Measure

• Description

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• Other

• Description

• Control Measure

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• Summary of Findings