Confined Space Hazard Evaluation Survey Form

Date of Survey / Confined Space # / Permit Required? / Yes o No o
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 o / No o / Potential hazardous atmosphere? (See A) / Yes o / No o
2.  Limited or restricted entry? / Yes o / No o / Potential for engulfment? (See B) / Yes o / No o
3.  Not designed for continuous human occupancy? / Yes o / No o / Internal configuration hazards? (See C) / Yes o / No o
Other serious safety hazard? (See D-G) / Yes o / No o
A.  Possible Atmospheric Hazards: O2 deficiency o O2 enrichment o Flammable o Toxic o
Specific hazard for flammable and/or toxic:
Comments:
B.  Possible Content/Engulfment Hazards: Previous contents o Content fill or removal o Shifting contents o Dust o
C.  Configuration of Space: Interior shape & slope o Low overhead clearance o Drop offs o
Complex layout o Stability o Structural integrity o
Comments:
D.  Potential Energy: Electrical o Hydraulic o Pneumatic o Mechanical o Fire control system o Steam o
E.  Environment in the Space
Slippery Surface o Ambient temperature high or low o Surface temperatures high or low o Noise o
Comments:
F.  Other Hazards: Animals o Insects o Biological organisms o Non-ionizing radiation o Ionizing radiation o
Comments:
G.  External Hazards that could impact safety in space: Traffic o Machinery o Equipment o Processes o Terrain o
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 o Production o Contractors o Other o
Frequency of entry / Number of entry points #
External connections to space
Eligible for Alternate Procedure?
(if Hazardous Atmosphere is ONLY hazard) / Yes o / No o / Eligible for Reclassification
(If NO hazardous atmosphere and ALL hazards can be eliminated before entry) / Yes o / No o
Comments:
Survey completed by

7/18/2016