Subcontractor Name: Project Location: Estimated Start Date Estimated End Date Work Order #: Project or Job Title: Project COTR’s Name: Contact Information: EHS POC: Contact Information: Subcontractor has a written PRCS Program per OSHA 1926 Subpart AA: Yes No Competent Person’s Name: Entry Supervisor’s Name: Contact Information: Contact Information: Competent person as defined in OSHA 1926 Subpart AA: OSHA 1926 Subpart AA Training Date: Yes No (attach certification) Confined space information: Scope of work in confined space: Type of space: Location: PRCS: Yes No Reclassification expected: Yes No Work will potentially introduce new hazards into PRCS: Yes No Explain: Confined space ID#: Potential confined space hazards: Energy sources present and means of isolation: Oxygen deficiency Energy Source: Energy control procedures: Oxygen enrichment Water Flammable/Explosive Gas Toxic Steam Entrapment Chemical Engulfment Waste Entanglement Mechanical Fall Electrical Electrical Other: Moving Parts Other: (attach LOTO procedures) PPE: Controls: Safety glasses Isolation of energy sources Face shield Purge the confined space Leather gloves Natural ventilation Rubber gloves Continuous forced ventilation Hearing protection Conduct Gas Testing & Monitoring Coveralls Entrance/exit points to be kept clear of all equipment Steel toe rubber boots Use of rescue/fall arrest equipment Steel toe boots Warning notices/barricades Hard hat Lighting Safety vest Fire extinguisher Personal floatation device Other, specify: Other, specify: List other specific equipment and how to be used:
Subcontractor Name: Project Location: Estimated Start Date Estimated End Date Work Order #: Project or Job Title: Project COTR’s Name: Contact Information: EHS POC: Contact Information: Subcontractor has a written PRCS Program per OSHA 1926 Subpart AA: Yes No Competent Person’s Name: Contact Information: Competent person as defined in OSHA 1926 Subpart AA: Yes No Entry Supervisor’s Name: Contact Information: OSHA 1926 Subpart AA Training Date: (attach certification) Confined space information: Type of space: Location: PRCS: Yes No Reclassification expected: Yes No Confined space ID#: Scope of work in confined space: Work will potentially introduce new hazards into PRCS: Yes No Explain: Potential confined space hazards: Oxygen deficiency Oxygen enrichment Flammable/Explosive Toxic Entrapment Engulfment Entanglement Fall Electrical Moving Parts Other: Energy sources present and means of isolation: Energy Source: Water Gas Steam Chemical Waste Mechanical Electrical Other: Energy control procedures: (attach LOTO procedures) PPE: Controls: Safety glasses Face shield Leather gloves Rubber gloves Hearing protection Coveralls Steel toe rubber boots Steel toe boots Hard hat Safety vest Personal floatation device Other, specify: Isolation of energy sources Purge the confined space Natural ventilation Continuous forced ventilation Conduct Gas Testing & Monitoring Entrance/exit points to be kept clear of all equipment Use of rescue/fall arrest equipment Warning notices/barricades Lighting Fire extinguisher Other, specify: List other specific equipment and how to be used:
EHS-CON-1.5confinedspacetemplate.docx