Confined Space Hazards Assessment Form

Project Name:
Reference No:
Client/Contractor:
Date:

To qualify as a confined space, the space in question must meet each of the following criteria:

1. The space is large enough to bodily enter. True False

2. The space has limited means of entry or egress. True False

3. Space is not designed for continuous human occupancy. True False

4. Does the confined space contain any recognized "Serious Hazard?"

If YES, space will be classified as Permit-Required Check
If NO, space will be classified as Non-Permit Required Check

Examples of "Serious Hazards" include but are not limited to:

Oxygen Deficiency Oxygen Enriched Entrapment

Engulfment Toxic Gas Combustible Gas

5. Is this space used for high voltage or electrical distribution? (E&U Only) Yes No
If you answered YES, your space qualifies as an Enclosed Space
6. Is this space used for water, steam distribution or telecommunications? (E&U Yes No
Only) If you answered YES, your space qualifies as a Mechanical Space

Based on the 5 questions you answered, determine the TYPE of space (Tick on YES/NO):

Non-Permit Required Confined Space Yes No

Permit-Required Confined Space Yes No

Enclosed Space Yes No

Mechanical Space Yes No

Harvard Building Name:

Location/Room Number of Confined Space:
Point of Access:
Reason For Entering the Space:
Entry Duration:
Frequency of Entry:

CONFINED SPACE HAZARD ASSESSMENT FORM-HSE DOCUMENTS Page 1 of 3

 7. Description of the Space

Based on the questions you answered, determine the TYPE of space (Tick on YES/NO):
Description of Space Yes No Description of Yes No Description of Yes No
Space Space
Air Handling Unit Electrical Vault Steam Manhole

Tunnel Sewer Vault

Pipe Chase Plenum Space Pipe Shaft
Manhole Water Meter Sump Pit
Manhole
Pit Sewer Ejector Pit Mechanical
Space
Boiler Stormwater Pit Telecom
Manhole
Crawl Space Tank Other

8. Major Hazards Identified (Check all that apply)

Based on the questions you answered, determine the TYPE (Tick on YES/NO):
Yes No Description of Yes No Description of Yes No
Description of Space
Space Space
Steam Excessive Noise
Oxygen Deficiency
Engulfment Protruding
Oxygen Enriched
Objects
Combustible Gas Entrapment Low Head Room
Slip, Trip, and Fall PCB-Containing
Toxic Gas
Oils
Asbestos Temperature
Chemical Contact Extremes
Low Light Electrical Hazards
Mechanical

Lockout-Tagout Combustion
Microbiological
Required Equipment in Use
High Wind Other
Dust Velocities

9. Entry Equipment Needs (Check All That Apply):

Yes No Description of Yes No Description of Yes No

Description of Space
Space Space
Respirator Chemical Apron Chemical Boots

Chemical Resistant Work Boots Chemical

Clothing Resistant Gloves
Face Shield Welding Shield Splash Goggles

CONFINED SPACE HAZARD ASSESSMENT FORM-HSE DOCUMENTS Page 2 of 3

 Hearing Protection Hard Hat Safety Glasses

Electrical Gloves Fall Protection Other

Equipment

** Minimum requirement for all confined spaces

10. Entry Equipment Needs (Check All That Apply):

Additional Information: Yes No

Comments: Yes No

Facility Manager Yes No

Supervisor: Yes No

Evaluator: Yes No

Evaluation Date: Yes No

Assessed by:

Date:

Signature:

CONFINED SPACE HAZARD ASSESSMENT FORM-HSE DOCUMENTS Page 3 of 3