Confined Space Assessment Form printable pdf download

Confined Space Assessment Form

Location of Space: _____________________________________________________________________

Type of Space: __________________________ Dimensions of Space: ____________________________

Date of Assessment: __________________________________Inventory Number:__________________

A. Confined Space Determination

1. Area was NOT designed for continuous human occupancy.

 YES

 NO

2. Area can be bodily entered and assigned work performed.

 YES  NO

3. Area has limited and or/restricted means of access and egress.

 YES  NO

If you answered yes to ALL of the above then the space has met the criteria for a confined space. Please

move on to the next section.

B. Permit‐Required Confined Space Determination

1. Does the space have or have the potential for a hazardous atmosphere?

 YES

 NO

If a hazardous atmosphere was detected, please mark the hazard(s) below:

 Oxygen Deficiency  Oxygen Enrichment  Explosive Gas/Vapor  Explosive Dust

 Hydrogen Sulfide  Carbon Monoxide  Chlorine  Other: _______________

2. Does the space have the potential to engulf the entrant?

 YES

 NO

Please mark below if the hazard poses a potential for engulfment:

 Water Sand Soil Gravel/Loose Rock  Sewage Oil Other: ______________

3. Does the space have the potential to entrap the entrant?

 YES

 NO

4. Is there a potential for any other serious safety and health hazard?

 YES

 NO

If yes, please mark below:

 Electrical  Moving Parts Slips and Trips  Falling (deeper than 5 ft.)  Heat  Cold

 Skin or Eye Irritants  Noise  Chemicals  Other:_________________________________

5. How is the space entered?

 Fixed Ladder (circle one: good condition or needs repair)  Stairs  Portable Ladder

 Lowering Winch (separate from non‐entry rescue equipment)

6. Will ventilation be required for the space?

 YES If YES: (check all that apply)  Natural Forced Positive Forced Negative

 NO

7. Will the entrant need to detach from the lifeline requiring rescue to be on site?

 YES

 NO

C. Alternate Entry Procedure Determination

1. If parts 2‐4 of Section B were marked YES, then alternate entry procedures are NOT allowed for

the space.

2. Is the only hazard an actual or potential hazardous atmosphere?

 YES  NO

If yes, will ventilation alone maintain safe conditions?

 YES

 NO

If yes has been marked for both questions in part 2, the space may use alternate entry procedures. If at

any time the space changes and other hazards are present, it is automatically a permit‐required space

again.

FINAL DETERMINATION:  Non‐Permit Confined Space  Permit‐Required Confined Space

 Alternate Entry Procedures Allowed

(Check All that Apply)

Confined Space Assessment Form

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