Confined Space Hazard Assessment
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CONFINED SPACE HAZARD ASSESSMENT
Confined Space Name/Location/Identification #:
Performed by:
Date:
Contents or use of Space: __________________________________________
Expected atmospheric hazard: ______________________________________
Hazard measured by: O Air monitoring O Other means ___________________
O Air monitor sensor required ______________________
1) Access to the Confined Space
Entrance/Exit Accessibility and Configuration (check a where applicable)
•
Entrance/Exit easily accessible O Yes
O No
•
Describe entrance/exit:
Location: O Top O Bottom O Side
Type: O Round O Oval
O Square O Other: _________________________________
Size (Diameter, etc.): _______________________________________________________
Vertical Entry/Exit O Yes
O No
O Stairs O Fixed Ladder O Portable Ladder O Other: ___________________________
Condition: ________________________________________________________________
Distance down/in: __________________________________________________________
Tripod to be used: O Yes
O No
Limitations: __________________________________
Other Method: O Yes
O No
Limitations: _____________________________________
Horizontal Entry/Exit O Yes
O No
Elevated entry/exit O Yes
O No
__________________________________________
Work platform provided for elevated entry O Yes
O No
O Not necessary __________
Distance in: _______________________________________________________________
Retrieval device to be used: __________________________________________________
Limitations: _______________________________________________________________
2) Internal Configuration and Features of Confined Space (check a where applicable)
•
Ceiling inside space:
Low ceilings O Yes
O No _________________________________________________
O Walk in
O Erect
O Stooped
O Crawl in
O Hands and Knees
O Stomach/Back
Head Hazards O Yes
O No _______________________________________________
•
Footing inside space:
O Flat surface
O Sloping Surface
O Uneven surface
O Slippery surface
O Cramped
O Climb/step over obstructions: _______________________________________________
O Tripping Hazards O Yes
O No __________________________________________
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