Confined Space Evaluation Form Page 2
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2UNIVERSITY OF MICHIGAN CONFINED SPACE ENTRY PERMIT
(Valid for maximum of one eight (8) hour shift and to be posted at work site.)
Type of Entry Permit (check one):
General
Hazardous*
Hot
Work**
(*
Contact OSEH 7-1142)
(**
Issue Hot Work Safety Permit)
Name of Entry Supervisor: _________________________________ Employee No.: _______________________
Work to be Performed: ______________________________________Duration:___________________________
Location of Permitted Confined Space: ___________________________________________________________
Pre-Entry Briefing Conducted by:____________________________ __________________________________
(Print)
(Signature)
Authorized Entrant(s): ____________________________________ __________________________________
____________________________________ __________________________________
(Name)
(Employee Number)
Attendant/Spotter Name: ___________________________________ __________________________________
(if required)
(Name)
(Employee Number)
** In case of emergency, Attendant will call UM DPS at 911 (from a campus phone) or on Radio Channel 1A **
Specific hazards which will be encountered
: ________________________________________________
(see reverse)
__________________________________________________________________________________________
Hazard control methods to be used: ______________________________________________________________
___________________________________________________________________________________________
Required equipment to be used:
(inspected and operational)
Personal Protective:
_______________________________________________
(respirator, clothing, etc.)
Air Monitoring: __________________________________________________________________
Retrieval / Rescue: _______________________________________________________________
Purge / Ventilation: _______________________________________________________________
Communication: _________________________________________________________________
Special Tools:
_________________________________
(approved electrical equipment, non-sparking tools, etc.)
Supplied Air / Self-Contained Respirators _____________________________________________
MONITORING RESULTS
O
LEL
H
S
CO
2
2
Monitoring
(%)
(%)
(ppm)
(ppm)
Sample
Other
Date/Time
Performed By
19.5–23.5%
< 10%
<15ppm
<35ppm
Location
(specify)
This confined space has been evaluated in accordance with the confined space entry procedures. All persons participating in this confined space
entry have been trained in confined space entry procedures. The creation or discovery of any work induced hazards or other unforeseen, actual,
apparent or potential hazards, requires the space be re-evaluated, additional precautions taken, and a new permit issued, if appropriate.
Hazardous entries must be reviewed and approved by OSEH (7-1142).
Entry Supervisor Signature
: ____________________________________ Date and Time: ______________
(Issued)
Entry Supervisor Signature
: ____________________________________ Date and Time: ______________
(Closed)
OSEH Authorization
: ________________________________ Date and Time: ______________
(Hazardous Entry Only)
Please return this form to OSEH: CSSB, 1239 Kipke Drive, Box 1010. Refer questions to OSEH at 647-1142.
Original: 10/97; Revised: 03/07
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