Confined Space Hazards Assessment Questionnaire Doc Ref #: XXXX/IMS/QHSE/F/00

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Name of the Organization Rev #: 00

Assessment Ref # Assessment Date

Project Reference Work Site Name
Area Location Client/Contractor
Prepared By Next Assessment

To declare a workplace as a Confined Space, it must meet the criteria mentioned in this questionnaire. The
questionnaire must be prepared by a competent person in the presence of Client/Contractor representatives.
S/# Criteria Yes No
1 The working space has enough space for a person to enter it and work there?
2 There are limited means of entering and exiting the workspace?
3 The space is not for continuous human occupancy?
4 does the confined space has any serious hazard that pose threat to human life?

Examples of Hazards existing in the workplace

S/# Tick the relevant hazards present in the workplace Yes No
1 Oxygen deficiency – Oxygen Level is less than 19.5% and requires oxygen line/BA?
2 Oxygen Enrichment – Oxygen Level is higher than 23.5%?
3 Entrapment?
4 Engulfment?
5 Toxic Gas? Carbon Monoxide (CO), Hydrogen Sulfide (H2S)
6 Combustible Gas? e.g., Methane, Butane, Propane, Hydrogen etc.

Type of Work Space

S/# Criteria Yes No
Is this work space used for High Voltage Electrical Distribution? If yes, designate it as Enclosed
1
Space.
Is this work space used for steam, water or any other fluid distribution? If yes, designate it as a
2
Mechanical Space.
Permit/Non-Permit Required Workspace
S/# Criteria Yes No
1 Does the Confined Space contain any identified Serious Hazard?
A If YES, it will be classified as PERMIT REQUIRED Confined Space.
B If NO, it will be classified as NON-PERMIT REQUIRED Confined Space.

Based on the answers of the question mentioned above, decide the type of Confined Space
S/# Type1 Check Type 2 Check
1 Non-Permit Required Confined Space Permit Required Confined Space
2 Enclosed Space Mechanical Space

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 Confined Space Hazards Assessment Questionnaire Doc Ref #: XXXX/IMS/QHSE/F/00
Logo QHSE Forms Issue Date: DD-MM-YYYY
Name of the Organization Rev #: 00

Work Space Details

S/# Criteria
1 ID # of the Confined Space
2 Means of Access/Egress
3 Reason for Entering the Space
4 Other Options to perform activity
5 Work Duration: (Entry to Exit)
6 Number of Entries/Frequency

Work Space Description - in terms of structure/physical existence

Type Yes No Type Yes No Type Yes No
Tank Electrical Vent Underground Pipe
Tunnel Manhole Sewerage pipe
Pips Chase Pit Sewer
Vault Pipe shaft Boiler
Storage Silo Mechanical Space Stormwater pit
Crawl space Fluid Transfer Pipe Others

Hazards Existing in the Workplace and Identified

Type Yes No Type Yes No Type Yes No
Oxygen Deficiency Oxygen enrichment Combustible gases
Toxic gases Corrosive gases Engulfment
Chemicals Corrosive substance Entrapment
Slip-trip-fall Mechanical hazard Biological hazard
Low light Asbestos High Temperature
Low Temperature Electrical hazard Dust
LOTO Required Low Head Space Excessive Noise
Trailing Wires Oils on Surface Others
Requirements before Entry and Commencement of Job
S/# Description of Space Yes No
1 Permit to work in confined space required.
2 Gas Testing required using standard gas tester by competent gas tester.
3 Chemical Resistant Clothing or Special PPEs required.
4 Face shield required.
5 Chemical Resistant Apron.

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 Confined Space Hazards Assessment Questionnaire Doc Ref #: XXXX/IMS/QHSE/F/00
Logo QHSE Forms Issue Date: DD-MM-YYYY
Name of the Organization Rev #: 00

S/# Description of Space Yes No

6 Permit to work in confined space required.
7 Work boots.
8 Chemical resistant boots.
9 Work gloves.
10 Chemical resistant gloves.
11 Welding shield.
12 Hearing protection.
13 Safety Helmet.
14 Electrical Protection Gloves
15 Fall protection and retrieval line.
16 Fire fighting equipment e.g., Fire Extinguisher
17 Medical Box
18 Workers should be trained and certified by competent person.
19 Attendant should be available to monitor the activity.
20 Others

Additional Information
Observation

QHSE Department Comments

Facility Manager Supervisor Evaluated By

Assessor Approved By

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