Confined Space Evaluation Form
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1
2APPENDIX C
CONFINED SPACE EVALUATION FORM
SPACE LOCATION: ________________________________________________________________
SPACE DESCRIPTION: ______________________________________________________________
Complete this form for any space which may be considered a confined space.
A confined space is defined as having those all characteristics listed in #1 through #3 below.
YES
NO
1. Is the space large enough and shaped so an employee can enter and work?
YES
NO
2. Does the space have a limited or restricted means for entry or exit?
YES
NO
3. Is the space NOT designed for continuous employee occupancy?
If the answers to all questions #1 through #3 above are “YES”, then the space is a Confined Space.
Continue with questions A through E below to determine if and what type of permit is required to enter.
YES
NO
A. Does the space contain, or have the potential to contain, a hazardous atmosphere, i.e.,
oxygen deficiency, flammable vapors, toxic gases or dusts, etc., or pipes, ducts, vents or
other entry points for potentially hazardous substances, or will volatile chemicals be
used, or will painting or other work that could create a breathing hazard be performed?
Specify potential or known hazards: ________________________________________
YES
NO
B. Does the space contain a material with the potential for engulfment of a worker, e.g.,
grain, sand or water?
Specify potential or known hazards: ________________________________________
YES
NO
C. Does the space have an internal shape such that a worker could be trapped or suffocated
by inwardly converging walls, floor or ceiling?
Specify potential or known hazards: ________________________________________
YES
NO
D. Does the space contain other recognized safety or health hazards, such as:
check all
(
that apply
)
___ mechanical hazards;
___ exposed or vulnerable electrical wires or energized equipment;
___ gas or chemical lines
___ special hazards related to elevation or falling; or
___ temperature extremes/heat stress
Specify potential or known hazards: ________________________________________
YES
NO
E. Will welding, cutting, torch work, or other hot work be performed?
Specify potential or known hazards: ________________________________________
If you answered “NO” to all questions A through E, then the space is a Non-Permit Required Confined Space.
If you answered “YES” to question A, then classify the Permit as either General or Hazardous, depending on
the ability to adequately ventilate the space.
If you answered “YES” to question B, C or D, then classify the Permit as a General if the hazards can be
controlled.
If you answered “YES” to question E, then classify the Permit as Hot Work & also issue a Hot Work Safety
Permit.
Name: ___________________________ Signature: __________________________________
Department: _________________________________________________________________
Refer questions to OSEH at 647-1142.
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