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Confined Space Form
Confined Space Entry Assessment
Assessment Date
Space Information
Job Name
*
Job Number
*
Verbal Space Designation
*
Numerical Space Designation
*
Space Marked
Yes
No
Entry Controlled
Yes
No
Signage
Yes
No
Barriers
Yes
No
Locks
Yes
No
Other
End Section
Related Operating Procedures Reviewed
Hazard Communication
Yes
No
Respiratory Protection
Yes
No
Electrical Safety
Yes
No
Lockout/ Tagout
Yes
No
Job Hazard Analysis
Yes
No
Process Safety
Yes
No
Welding Safety
Yes
No
Accident Investigation
Yes
No
Fire Prevention
Yes
No
Other
End Section
Next
Confined Space Assessment Checklist, Part 1
If any answers to 1,2, or 3 are "No", this space will be considered a Non-Confined Space.
1. Can an employee enter & perform work either with or without permission?
Yes
No
2. Do people occupy the space even though it was not designed for it?
Yes
No
3. Is entry and or egress limited or present unusual rescue problems?
Yes
No
End Section
Next
Confined Space Assessment Checklist, Part 2
If answers to 4, 4a, and 4b are all Yes, this will be considered an Alternate Space.
4. Does the space have any potential for a hazardous atmosphere?
Yes
No
4a. Is hazardous atmosphere the ONLY potential or actual hazard?
Yes
No
4b. Can the atmospheric hazard be eliminated via ventilation?
Yes
No
End Section
Next
Confined Space Assessment Checklist, Part 3
5. Does the space contain a material or liquid that could engulf an entrant?
Yes
No
6. Does the internal space configuration present the hazard of entrapment?
Yes
No
7. Does the space contain any other recognized safety and or health hazards?
Yes
No
End Section
Next
Assessed Hazards
Select a Hazard
Restricted Entry/ Egress
Oxygen Deficiency*
Oxygen Enrichment*
Oxygen Displacement
Flammable Gases or Vapors*
Toxic Gases or Vapors*
Airborne Combustible Dusts*
Chemical Hazards
Mechanical Hazards
Electrical Hazards
Respiratory Hazards
Engulfment Hazards
Potential for Excessive Flow
Entrapment Hazards
Fall Hazards
Skin Hazards
Hot/Cold Hazards
Radiation Hazards
Biological Hazards
Toxic Liquids
Potential High Liquid Level
Internal Baffles
Measurement/ Notes
PPE Req'd
Oxygen Deficiency
: Less than 19.5%
Oxygen Enrichment
: More than 23.5%
Flammable Gases or Vapors
: More than 10% LEL
Toxic Gases or Vapors
: More than PEL
Airborne Combustible Dusts
: Meets/ Exceeds LFL
Potential for Excessive Flow
: Large diameter pipe, changes in flow
End Section
Next
Space Properties
Configuration
-Pick one-
Manhole
Pit
Vault
Sewer
Pipeline
Inlet
Other
Configuration
Location
Elevated
Above Ground
Below Ground
Anticipated Rescue
Vertical Extraction
Horizontal Extraction
Other
Anticipated Rescue
Depth/ Height
Width/ Inner Diameter
Length
Volume/ Capacity
Shape
End Section
Next
Remarks/ Recommendations
Image Upload
Notes
I certify that I have conducted a confined space assessment of the above designated space. To the best of my knowledge, I believe the information contained herein to be true and accurate as of the time of the assessment.
Assessment Complete?
*
Yes, consider this assessment completed
No, just save the data for later
End Section
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