NEW Blank Confined Spaces Assessment Worksheet.docx

ASSESSMENT TEAM

SECTION 1. SPACE LOCATION

Building/Non-Building Space: If the space is inside a building, fill in the “Building Space” block below. If the space is not inside a building, fill in the “Non-Building Space” block below.

Building Space Building Number:

Non-Building Space

GPS:

Dimensions (Measure or estimate the space dimensions) Length: Width:

Depth: Entry/Access Dimensions:

Will personnel enter the space? YES _____ NO _____

Check all personnel who may enter the space.

x Military DoD Civilians Contractor Other:

SECTION 2. CONFINED SPACE EVALUATION

Is the space large enough to allow the worker to bodily enter and perform work?

Is there limited or restricted means of entry or exit?

Is the space not designed for continuous employee occupancy?

Is the space a ‘Confined Space?’ (NOTE: “Yes” to all of the above questions indicates a confined space.)

SBD 2 Safety

CONFINED SPACE ASSESSMENT WORKSHEET

SECTION 3. FUNCTION OF THE CONFINED SPACE

Check the category that best describes the space.

1. Baghouse

8. Crawlspace

2. Cyclone

9. Excavation/Trench

3. Furnace

10. Incinerator

4. Fuel Cell

11. Oil/Water Separator

5. Sewage Digester

12. Tunnel

6. Vat

13. Vault

7.2. Sewer

14.2. Other (List)

7.3. Lift Station

Comments/Remarks:

7.4. Septic Tank

7.5. Storm Drain

7.6. Telephone

7.7. Other (list)

b. Unfired

b. Fuel: (Non usable, sealed shaft)

SECTION 3. (continued) FUNCTION OF THE CONFINED SPACE

c. Sewage

b. Fan

d. Steam

c. Duct

e. Other (List)

17. Tank

AG = Above Ground

UG = Under Ground

a. Clarifier

b. Condensate

b. Reaction

c. Degreaser

c. Other (list)

d. Fuel (AG)

e. Fuel (UG)

b. Water

f. Inerted

c. Other (list)

g. Septic

h. Solvent (AG)

b. Coal

i. Solvent (UG)

c. Other (list)

j. Storage (UG)

22. Other (list) Radome

k. Storage (AG)

l. Water (AG)

Comments/Remarks:

m. Water (UG)

n. Other (list)

SECTION 4. ASSESSMENT OF POTENTIAL OR ACTUAL HAZARDS OF THE SPACE – BY TYPE

Hazard Inventory (Determine if the following hazards currently exist, may potentially exist, or be introduced into the space by assigned tasks in the space. Check the appropriate box for each hazard. Check Yes, No, or Potentially.)

1. Biohazard

11. Machinery

2. Combustibility

12. Oxygen Displacement/Enrichment

3. Electrical

13. Process

4. Engulfment

14. Radiation (Ionizing)

5. Entrapment

15. Radiation (Non-ionizing)

6. Flammable Materials

16. Temperature Extremes

7. Hazardous Material Present

17. Unfavorable Ventilation

8. IDLH Environment

18. Other : Remoteness of Site

9. Inert Atmosphere

19. Other: Hazards introduced from an environment external to the space

10. Introduction of Hazardous Material

20. Other: Slippery surfaces, deteriorated or unstable ladders

SECTION 5. INITIAL TESTING OF CONFINED SPACE ATMOSPHERIC CONDITIONS

Hazard Readings (Document readings, instrument, and calibration information.)

LEL

Hazard > 10% of LFL*

Oxygen Hazard < 19.5 % or > 23.5%

CO2

H2S

Instrument Used

Serial Number:

Tested By:

Date/Time:

Method:

Criteria:

Calibrated By:

Date/Time

* Lower Flammable Limit (LFL) is referenced in CFR 1910.146. It is synonymous with Lower Explosive Limit (LEL).

SECTION 6. PERMIT-REQUIRED CONFINED SPACE EVALUATION

Using the results from Sections 4 and 5 check the appropriate answer to each question.

(NOTE: This is only a preliminary investigation and spaces may later be re-classified.

Is there a potential for the space to contain a hazardous atmosphere?

Is there a potential for the space to contain a material for engulfing an entrant?

Does the space have a configuration such that an entrant could be trapped or asphyxiated?

Does the space have any recognized safety or health hazards (e.g., unstable ladders, possible Hantavirus)?

Is the space a Permit-Required Confined Space?

(NOTE: “YES” to any of the above questions indicates the space is a Permit-Required Confined Space.)

SECTION 7. INADVERTENT ENTRY

Can the space be entered inadvertently? (NOTE: IF ‘Yes,” signage is required)

Method to prevent inadvertent entry (in addition to posted signs):

SECTION 8. ADDITIONAL COMMENTS/REMARKS

SECTION 9. COORDINATION AND SIGNATURES

SBD 2/SE)

SBD 2/SE

CONCUR

NON-CONCUR

SIGNATURE DATE

460 CES/CEF

460 ORMS/SGXB