• Document No.

  • Site Name

  • Description of Space

  • Conducted on

  • Prepared by

  • Location
  • Dimensions L x W x H

  • Is this space entered on a routine basis?

Nature of Potential Hazards

  • Potential Atmospheric Hazards

  • Potential Non-Atmospheric Hazards

  • Contains material which could engulf entrant?

  • Internal config could trap entrant?

  • Electrical (live circuits)?

  • Mechanical (pipe / leakage)?

  • Slick residue covered surface?

  • Equipment preventing safe exit?

  • Low inadequate lighting?

  • Hazardous chemicals present?

  • Fall potential?

  • Potential for dropped objects?

  • Multiple work groups / nature of work?

  • Other?

  • Pictures

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.