University of Minnesota Confined Space Hazard Evaluation

• Confined Space Hazard Evaluation and Classification

• Client / Site

• Conducted on

  Date

• Prepared by

IDENTITY AND DESCRIPTION OF SPACE UNDER EVALUATION

• Name of space

• Are there similar/identical spaces elsewhere at this facility? If yes, how many, and where are they located?

• Name(s) of person(s) evaluating space

• Date of evaluation

  Date

• Description of physical characteristics of space (i.e. measurements, above/below grade, volume, contents, purpose, etc.)

IS THIS SPACE A "CONFINED SPACE"? You must determine if the space meets the definition of a "confined space" prior to determing if it's a "permit-required confined space". If you answer "yes" to ALL of the questions below, then the space is considered a "confined space" and you must continue to the next section for further evaluation. If you answer "no" to ANY of the following questions, then the space is NOT a confined space. Do NOT proceed to the next question, and enter "Not a confined space" In the "RESULTS OF EVALUATION" section. Stop.

• Is the space large enough and configured that a person can bodily enter and perform assigned work?

  Yes

  No

• Does the space have limited or restricted means of entry and egress (i.e. does an entrant need to climb a ladder, crawl through a manhole, or change the position of his/her body for ingress/egress)?

  Yes

  No

• Is the space NOT designed for continuous human occupancy?

  Yes

  No

IS THIS CONFINED SPACE A "PERMIT-REQUIRED CONFINED SPACE"? A "permit-required confined space" is a space which meets the definition of "confined space", AND contains some type of hazard, such as unguarded, moving parts or a hazardous atmosphere. If you answer "yes" to ANY of the following questions, then the space is a "permit-required confined space" and you must continue to the next sections for further evaluation. If you answer "no" to ALL of the following, then the space is NOT a permit-required confined space. Do NOT proceed to the next question, and enter "Not a permit-required confined space" In the "RESULTS OF EVALUATION" section. Stop.

• Does the space contain, or have the realistic potential to contain a hazardous atmosphere, such as Oxygen concentrations below 19.5% or greater than 23.5%, or ACUTELY toxic atmosphere such as Hydrogen Sulfide or Carbon Monoxide (chronic hazards are excluded), flammable or explosive atmospheres? Are there pipes, ducts, or sources of potentially hazardous substances? Will hazardous chemicals be used in the space, or will painting, sealing, or other work within the space create a possible hazardous atmosphere?

  Yes

  No

• Describe.

• Does the space contain, or have the potential to unexpectedly develop an engulfment hazard (i.e. sand, grain, water/flash flooding)?

  Yes

  No

• Describe.

• Does the space have inwardly converging walls that taper downward to a smaller cross section, or floors that slope downward that could cause entrapment or asphyxiation?

  Yes

  No

• Describe.

• Does the space contain mechanical hazards such as moving parts, unguarded/hazardous machinery, etc.?

  Yes

  No

• Describe.

• Does the space contain exposed or vulnerable electrical conductors, connections, or parts?

  Yes

  No

• Describe.

• Does the space contain vulnerable gas or chemical pipelines or similar?

  Yes

  No

• Describe.

• Does the space contain special hazards related to elevation, or falling?<br>

  Yes

  No

• Describe.

• Does the space contain, or have the potential to contain temperature or heat stress hazards?

  Yes

  No

• Describe.

• Does that space contain equipment or configurations that would complicate the rescue/extraction of an unconscious entrant?

  Yes

  No

• Describe.

• Does the space contain any other significant hazard?

  Yes

  No

• Describe.

IS THIS PERMIT-REQUIRED CONFINED SPACE A "TYPE 3" PRCS? If you answer "yes" to ALL of the following questions, then the space is a "type 3 permit-required confined space". Do NOT proceed to the next section. Enter "Permit-Required Confined Space - Type 3" in the "RESULTS OF EVALUATION" section. Stop. If you answer "no" to ANY of the following questions, then the space is NOT a "type 3 permit-required confined space" and you must continue to the next sections for further evaluation.

• Is the space free of hazardous atmospheres, and the reasonable possibility of developing hazardous atmospheres?

  Yes

  No

• Can ALL other hazards be temporarily controlled or eliminated WITHOUT entering the space (i.e. by locking out moving parts, or by wearing proper fall protection)?

  Yes

  No

  Not Applicable

• Describe.

IS THIS PERMIT-REQUIRED CONFINED SPACE A "TYPE 2" PRCS? If you answer "yes" to ALL of the following questions, then the space is a "type 2 permit-required confined space". Do NOT proceed to the next section. Enter "Permit-Required Confined Space - Type 2" in the "RESULTS OF EVALUATION" section. Stop. If you answer "no" to ANY of the following questions, then the space is NOT a "type 2 permit-required confined space" and you must continue to the next sections for further evaluation.

• Is the ONLY hazard of this space a hazardous or potentially hazardous atmosphere?

  Yes

  No

• Is continuous mechanical forced air ventilation ALONE sufficient to maintain a safe atmosphere?

  Yes

  No

  Not Applicable

• Are there formal, written evaluations by a qualified professional to support the conclusion above?

  Yes

  No

  Not Applicable

• Describe.

IS THIS PERMIT-REQUIRED CONFINED SPACE A "TYPE 1" PRCS? If you have reached this point and concluded that the space is NOT a type 2 or 3, then the space is a type 1 PRCS. Enter "Permit-Required Confined Space - Type 1" in the "RESULTS OF EVALUATION" section. Stop.

RESULTS OF EVALUATION Check only one option

• Not a confined space

• Confined space, but not permit-required

• Permit-required confined space - Type 1

• Permit-required confined space - Type 2

• Permit-required confined space - Type 3

WHO IS PERMITTED TO ENTER THE SPACE? Check all that apply.

• Properly trained and equipped contractors

• Properly trained and equipped University/location staff

• Entry is not permitted by any person