Confined Space Hazard Assessment Page 2
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Other internal features of space:
Poor lighting O Yes
O No ________________________________________________
Sharp objects O Yes
O No _______________________________________________
Spilled Chemicals O Yes
O No ____________________________________________
Rusty Surfaces O Yes
O No ______________________________________________
Animal/Insects O Yes
O No ______________________________________________
Chemical coated walls/surfaces O Yes
O No _________________________________
Biological residue/slime O Yes
O No _______________________________________
Liquids on floor/walking surfaces (standing water) O Yes
O No ___________________
Pipelines going through the space O Yes
O No _______________________________
Materials in pipes/lines: _____________________________________________________
Pipes with mechanical joints (flanges, valves) inside space: _________________________
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Site Support:
O Grounding point available O Yes
O No
O NA _____________________________
O Electrical services present O Yes
O No
O NA ____________________________
O Anchorage points for rescue O Yes
O No
O NA ___________________________
3) Electrical Hazards O Yes
O No
Possible contact with energized conductors O Yes
O No _________________________
_________________________________________________________________________
Lockout procedures required O Yes
O No
Lockout points identified O Yes
O NA
4) Mechanical Hazards O Yes
O No
Moving/Rotating belts, blades, gears, pinch points, etc. O Yes
O No _______________
_________________________________________________________________________
Lockout procedures required O Yes
O No
Lockout points identified O Yes
O NA
5) Hydraulic/Pneumatic Hazards O Yes O No
If “Yes” continue; if “No” proceed to #10:
Hydraulic O Yes
O No ___________________________________________________
Pneumatic O Yes
O No __________________________________________________
6) Engulfment Hazards O Yes
O No
O Liquid
O Powder/Grains
O Sludge/Sewage ________________________________
7) External Hazards O Yes
O No
O Traffic hazard
O Parking Lot (loading area/parking spaces in vicinity)
O Precipitation
O Overhead electrical wires
O Spill or possibility of objects falling into opening
8) Other Considerations: Hot Work
O Yes
O No
If “Yes” continue below; if “No” proceed to #13:
O Welding
O Cutting
O Grinding
O Power Tools
O Other _________________
9) Other Considerations: Ventilation
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