Zzzzz Confined Space Hazard Assesment

• Document No.

• Site Name

• Description of Space

• Conducted on

  Date

• Prepared by

• Location
  Address

• Dimensions L x W x H

• Is this space entered on a routine basis?

  Yes

  No

  N/A

Nature of Potential Hazards

• Potential Atmospheric Hazards

  Select O2 Deficient / Enriched Combustibles / Flammables CO H2S Other Toxics

  • O2 Deficient / Enriched
  • Combustibles / Flammables
  • CO
  • H2S
  • Other Toxics

• Potential Non-Atmospheric Hazards

• Contains material which could engulf entrant?

  Yes

  No

  N/A

• Internal config could trap entrant?

  Yes

  No

  N/A

• Electrical (live circuits)?

  Yes

  No

  N/A

• Mechanical (pipe / leakage)?

  Yes

  No

  N/A

• Slick residue covered surface?

  Yes

  No

  N/A

• Equipment preventing safe exit?

  Yes

  No

  N/A

• Low inadequate lighting?

  Yes

  No

  N/A

• Hazardous chemicals present?

  Yes

  No

  N/A

• Fall potential?

  Yes

  No

  N/A

• Potential for dropped objects?

  Yes

  No

  N/A

• Multiple work groups / nature of work?

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

• Pictures

  Media