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Confined Space Hazard Assessment Template

Download and use this confined space risk assessment to identify and isolate hazards. There are different risks associated with the different types of confined space work, so it’s essential you walk through every checkpoint, as some have more than one hazard. Below, are a couple of examples of the types of checkpoints you’ll encounter in this template:

  • • Authorized entry points
  • • Permit to work
  • • Explosive atmosphere
  • • Combustible materials
  • • Electrical circuits
  • • Toxic gasses
  • • Toxic material
  • • Thermal hazards
  • • Dangerous machinery
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Audit
Space ID Number
Date of last assessment
Confined Space - must meet all of the criteria below
Is large enough or so configured that an employee can bodily enter and perform work and
Has limited or restricted means for entry and exit and
Is not designed for continuous employee occupancy
Permit Required Confined Space -must be a confined space and meets any of the criteria below
Contains or has the potential to contain a hazardous atmosphere or
Contains a material that has the potential for engulfing an entrant
Has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor that slopes downward and tapers to a smaller cross-section or
Contains any other recognized serious safety or health hazard
Authorized Entry Points
Top
Side
Bottom
Hazards - Explosive Atmosphere
Source type
Quantity and quality (LEL)
Severity
Hazard abatement method
Hazards - Combustible Material
Source type
Quantity and quality
Severity
Hazard abatement method
Hazards - Electrical Circuits
Source type
Quantity and quality
Severity
Hazard abatement method
Hazards - Toxic Gases
Source type
Quantity and quality (PEL)
Severity
Hazard abatement method
Hazards -Toxic Material
Source type
Quantity and quality
Severity
Hazard abatement method
Hazards - Thermal Hazards
Source type (degrees Fahrenheit)
Quantity and quality
Severity
Hazard abatement method
Hazards - Machinery
Source type
Severity
Hazard abatement method
Hazards - Slip and Fall Hazards
Source type
Severity
Hazard abatement method
Hazards - Engulfment Hazards
Source type
Severity
Hazard abatement method
Hazards - Entrapment Hazards
Severity
Source type
Hazard abatement method
Hazards - Pneumatic/Kinetic Energy
Source type
Severity
Hazard abatement method
Personal Protective Equipment Required
Gloves
Coveralls
Hearing protection
Safety glasses
Hard hat
Goggles
Air supplied respirator
SCBA
Line fed
Ventilation Requirements
Space volume in cubic feet
Natural circulation - no atmospheric hazards in place. Additional ventilation may be required for worker comfort, hot work, grinding, or other operations that would produce airborne fumes, mist or dust. Entry Supervisor must assess additional ventilation requirements based on tasks to be performed in the space prior to time of entry.
Mechanical ventilation
Supply
Volume, in cubic feet per minute
Point
Exhaust
Volume, in cubic feet per minute
Point
Local
Volume, in cubic feet per minute
Point
Ventilation Formulas and Requirements
20 Air Changes per Hour. (ACH) required for duration of entry. 20 ACH = space volume x 20
Adequate Blower Capacity (ABC). ABC = space volume x 20 ACH, divided by 60 minutes.
Initial Purge Time. 7.5 x space volume, divided by effective blower capacity.
Required Rescue and Safety Equipment (check if required)
Lifeline
Body harness
Floor level opening barrier
Tripod
Powered communication
Portable lighting
Atmosphere make and model
Electrical equipment
Monitor
Man winch
Fall arrest unit
Emergency retrieval line
Blower
Vent saddle
Vent truck
Ladder
Emergency escape respirators
APR Respirator Cartidges
Acid/gas
OV
DMF
N-95
R-95
P100
Acceptable Entry Conditions
Confined space entry permit closed
Oxygen 19.5-23.5%
Lower explosive level 10%
Toxic fumes/vapors less than PEL
No engulfing materials in space
Continuous air monitoring
Space drained, flushed
Training verified for Supervisor, entrants and attendants
LOTO electrical components in use
LOTO mechanical components in use
LOTO all pipes to and from space
Forced mechanical ventilation established and maintained
No hazardous chemicals or materials
Rescue team available
Pre-entry brief completed
Training verified for rescue team
Maximum internal temperature
Minimal internal temperature
Communication Procedures (between attendant and entrants)
Wireless radio
Line radios
Verbal from access
Line of sight
Rescue Procedures
Self rescue
Non-entry rescue
Rescue team entry
Notes
Notes
Determination
This space has been determined to be a:
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.

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