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  • Confined Space Hazard Evaluation Survey Form

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    This confined space hazard evaluation survey form is used to assess whether a space is a permit-required confined space. It involves documenting the date, location, and description of the space. It then evaluates if the space can be entered, has restricted entry, and is not designed for human occupancy. It also evaluates if there are any atmospheric, engulfment, configuration, energy, environmental, biological, or external hazards. Based on these criteria it determines if the space requires a permit and what signage or security measures are needed. It also documents entry reasons, activities, entrants, and any external connections. It concludes by assessing if alternate procedures or reclassification may apply.

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    This confined space hazard evaluation survey form is used to assess whether a space is a permit-required confined space. It involves documenting the date, location, and description of the space. It then evaluates if the space can be entered, has restricted entry, and is not designed for human occupancy. It also evaluates if there are any atmospheric, engulfment, configuration, energy, environmental, biological, or external hazards. Based on these criteria it determines if the space requires a permit and what signage or security measures are needed. It also documents entry reasons, activities, entrants, and any external connections. It concludes by assessing if alternate procedures or reclassification may apply.

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    74 views2 pages

    Confined Space Hazard Evaluation Survey Form

    Uploaded by

    Edward
    This confined space hazard evaluation survey form is used to assess whether a space is a permit-required confined space. It involves documenting the date, location, and description of the space. It then evaluates if the space can be entered, has restricted entry, and is not designed for human occupancy. It also evaluates if there are any atmospheric, engulfment, configuration, energy, environmental, biological, or external hazards. Based on these criteria it determines if the space requires a permit and what signage or security measures are needed. It also documents entry reasons, activities, entrants, and any external connections. It concludes by assessing if alternate procedures or reclassification may apply.

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    © All Rights Reserved
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    Confined Space Hazard Evaluation Survey Form

    Date of Survey Confined Space # Permit Required? Yes  No 


    Location of Space (include Building # of closest building)

    Description of Space, including dimensions

    Confined Space if 1 – 3 below are ALL “Yes” Permit Required Confined Space if ANY below are “Yes”
    1. Can be bodily entered? Yes  No  Potential hazardous atmosphere? (See A) Yes  No 
    2. Limited or restricted entry? Yes  No  Potential for engulfment? (See B) Yes  No 
    3. Not designed for continuous Yes  No  Internal configuration hazards? (See C) Yes  No 
    human occupancy? Other serious safety hazard? (See D-G) Yes  No 
    A. Possible Atmospheric Hazards: O2 deficiency O2 enrichment Flammable Toxic 
    Specific hazard for flammable and/or toxic:
    Comments:

    B. Possible Content/Engulfment Hazards: Previous contents Content fill or removal Shifting contents Dust

    C. Configuration of Space: Interior shape & slope Low overhead clearance Drop offs 
    Complex layout Stability Structural integrity 
    Comments:

    D. Potential Energy: Electrical Hydraulic Pneumatic Mechanical Fire control system Steam 
    E. Environment in the Space
    Slippery Surface Ambient temperature high or low Surface temperatures high or low Noise 
    Comments:

    F. Other Hazards: Animals Insects Biological organisms Non-ionizing radiation Ionizing radiation 
    Comments:

    G. External Hazards that could impact safety in space: Traffic Machinery Equipment Processes Terrain

    Comments:

    If hazard evaluation determines this to be a PRCS, is space posted with signs or secured/locked indicating PRCS?

    Reasons for entering space & typical activities

    Who usually enters space? Maintenance Production Contractors Other 


    Frequency of entry Number of entry points #
    External connections to space

    Eligible for Alternate Procedure? Yes  No  Eligible for Reclassification Yes  No 


    (if Hazardous Atmosphere is ONLY (If NO hazardous atmosphere and ALL
    hazard) hazards can be eliminated before entry)
    Comments:

    Survey completed by

    4/28/2019
    Confined Space Hazard Evaluation Survey Form

    4/28/2019

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