Facility Name: __________________________________________________________
Project Name: __________________________________________________________
Space: ________________________________________________________________
Location: ______________________________________________________________
Completed By: _________________________________________________________
Date/Time Completed: ___________________________________________________
You must use the following criteria to decide if the space listed above is a confined space: (Note: Go to 242 FW 11, section 11.3 to read a definition of confined space.)
_____ The space is enclosed;
_____ The space is large enough and is shaped so that an employee can enter and perform job tasks;
_____ The space has limited or restricted means to enter or exit (for example, manholes, tanks, trenches, vessels, silos, storage bins, hoppers, vaults, pits, wells, and diked areas); and
_____ The space is not designated for continuous occupancy.
If you check all 4 blanks, the space is a confined space.
You must use the following criteria to determine if a confined space is a permit-required confined space: (Note: Go to 242 FW 11, section 11.3B to read the definition of permit-required confined space.)
_____ The space contains a hazardous atmosphere or a known potential to contain a hazardous atmosphere.
_____ The space contains a material with the potential for engulfing an entrant (for example, grain, ore, sand, liquid, etc.). (Note: Go to 242 FW 11, section 11.7C to read the definition of engulfment.).
_____ The space is configured so that an entrant could be trapped or asphyxiated by inwardly converging walls, or a floor that slopes downward and tapers to a smaller cross-section.
_____ The space has some other recognized serious safety or health hazard.
If you checked any of the 4 blanks, the space is a permit-required confined space.