CONFINED EVALUATION FORM Date of Survey Confined # Permit Required Yes No If yes, space must be labeled. Location of Space Description of Space Possible atmospheric hazards Possible content hazards Configuration of space Unusual hazards 1. Space can be bodily entered? No 4. Hazardous atmosphere? No 2. Limited or restricted entry? Yes No 5. Potential for engulfment? No 3. Not designed for continuous human occupancy? 6. Internal configuration hazard? No No 7. Other serious safety hazards? No Reasons for entering and typical activities Who usually enters space Frequency of entry Number of entry points External connections to space Survey completed by: (print and sign)
CONFINED EVALUATION FORM Date of Survey Confined # Permit Required Yes No If yes, space must be labeled. Location of Space Description of Space Possible atmospheric hazards Possible content hazards Configuration of space Unusual hazards 1. Space can be bodily entered? No 2. Limited or restricted entry? Yes No 3. Not designed for continuous human occupancy? No 4. Hazardous atmosphere? No 5. Potential for engulfment? No 6. Internal configuration hazard? No 7. Other serious safety hazards? No Reasons for entering and typical activities Who usually enters space Frequency of entry Number of entry points External connections to space Survey completed by: (print and sign)
Developing-a-Contractors-Safety-Program.docx