Confined space hazard assessment checklist
What does this form include?
This form contains 45 sections:
Audit Title
Prepared By
Location Address
Type of Space
- Permit Required
- Non-Permit
- Non-Permit w/ Conditions
- Prohibited Entry
Date of Initial Assessment Date
Date of Most Recent Review Date
Use of Space
Entry Point 1 - Type
Entry Point 1 - Elevated
Entry Point 2 - Type
Entry Point 2 - Elevated
Entry Point 3 - Type
Entry Point 3 - Elevated
Confined space
- Is the space large enough and so configured that a Partner can bodily enter and perform work?
- Does the space have limited or restricted means of entry or exit?
- Is the space NOT designed for continuous occupancy?
- Is this a Confined Space?
Permit Required Confined Space
- Does this space have the potential for containing a hazardous atmosphere?
- Does the space contain a material which has the potential for engulfing an entrant?
- Does the space have an internal configuration such that an entrant could be trapped or asphyxiated by inwardly sloping walls or by a floor which slopes downward and tapers to a smaller cross section?
- Does the space contain any other recognized serious safety or health hazards?
- Is this a Permit Required Confined Space?
How often is this space entered?
- Daily
- Weekly
- Monthly
- Annually
- Emergency Only
Nature of Hazard
Hazard Source / Type
Hazard Abatement Method
Ventilation Requirements?
- Ventilation Requirements?
Volume of Space in Cubic Feet?
Natural Ventilation Required?
- Natural Ventilation Required?
- Mechanical Ventilation Required?
Initial Purge Time (IPT) = (7.5 x Volume) / Fan CFM
You must ventilate the space by a minimum of the Initial Purge Time if you detect a gas level outside
PPE Required for Entry
- Chemical Gloves
- Work Gloves
- Coveralls
- Hearing Protection
- Safety Goggles
- Face Shield
- Hard Hat
- Dust Mask
- Chemical Protective Clothing
- Steel Toed Boots
- Other
Respiratory Protection Required for Entry
- SCBA
- Air Line Respirator
- Full Face Air Purifying Respirator
APR Cartridge / Canister Type
Is Rescue Equipment needed?
- Is Rescue Equipment needed?
Full Body Harness
- Full Body Harness
- Life Line
- Tag Line
- Radio
- Ladder
- Winch
- Mechanical Advantage System
- Barrier Guard
- Class 1, Div 1 Electrical Equipment
- Spark Proof Tools
- Tripod
- Portable Lighting
- Forced Air Blower
- Respirators
- Other
Communication Procedures
- Handheld Wireless Radio
- Line Radio
- Voice from Entry Point
- Hand Signals
- Other
Is Atmospheric Monitoring Required?
- Is Atmospheric Monitoring Required?
LEL
- LEL
- O2
- H2S
- Cl
- ClO2
- NH3
- CO2
- CO
- HCOH
Acceptable Entry Conditions
- Entry Permit Posted
- O2: 19.5% - 23.5%
- LEL: < 10%
- Toxic Gas Below PEL
- No Engulfment Hazard
- Air Monitoring In Place
- Space / Lines Drained / Flushed
- Internal Temperatures < 115F
- Lockout / Tag out In Place
- Feed Line Blocked
- Ventilation In Place
- Rescue Plan In Place
- Pre-Entry Inspection / Brief Conducted
- No Hazardous Materials Introduced Into Space
- See Specific Procedures Section
Overall View of Confined Space
Entry Point 1
Entry Point 2
Entry Point 3
Prohibited Entry Conditions
Pre-Entry Procedures
Exceptions
Entry Procedures
Rescue Procedures
Keep this confined space hazard assessment on file and readily accessible to authorized and trained "
No entries are to be permitted unless "acceptable entry conditions" are present. Entry into a Confine
Use this template