Confined Space Identification & Hazard Identification Checklis

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Question Set Question
Section 1: Confined Space
Location of space (e.g., site, area, room):
Identification and Location

Section 1: Confined Space Description of space (physical characteristics,

Identification and Location configuration, number of entry points, etc.):

Section 1: Confined Space Person in charge of space or responsible

Identification and Location individual:

Section 1: Confined Space

Is the space a confined space?
Identification and Location

No action is necessary for non-permit confined

spaces unless personnel are entering non-
permit spaces and there are changes within
Section 5: Non-Permit Confined
these spaces that may increase or create a
Space Entry
hazard to entrants. If such a situation occurs,
the space must be reevaluated, and if
necessary, reclassified as a PRCS.

Section 5: Non-Permit Confined

Date:
Space Entry
Section 5: Non-Permit Confined
Location of space:
Space Entry
The following conditions and precautions are
Section 5: Non-Permit Confined
required for safe entry into this non-permit
Space Entry
confined space:

The following changes within this non-permit

Section 5: Non-Permit Confined confined space constitute a "change in
Space Entry conditions" and require a re-evaluation of the
space prior to entry:
 In all cases, if hazards arise during non-permit
confined space entry, all personnel must leave
Section 5: Non-Permit Confined the space immediately. Confined spaces must
Space Entry be re-evaluated whenever there are changes in
the use or configuration of the space or when
hazards change or arise.

This checklist provides general information and

is meant as an example checklist only. This is
not to be considered advice, nor treated as
such. The information provided herein is
Disclaimer
provided without any representations or
warranties – express or implied and Certainty
Software Inc. makes no representations or
warranties in relation to this checklist.
n & Hazard Identification Checklist
Snapshot ID Date
322
Answer Type

Location

Description

Person

1. The space can be entered?

2. The space has limited or restricted entry and exit?
3. The space is not designed for continuous human occupancy?

Date

Location

Non-permit conf.

1.
2.
3.
4.
5.
Signature of certifying individual:
 Time

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