Confined Space Evaluation & Information Form
ReconAfrica
Date:
-
Month
-
Day
Year
Date
Entry Supervisor:
First Name
Last Name
Supervisor Email:
example@example.com
Lease/Location Name:
Location at Facility:
Specific Process Equipment Name & Number:
Type of Confined Space:
Tank/Vessel
Pit/Vault/Cellar
Trench/Excavation
Other
If Tank/Vessel, What Type?
Vertical
Horizontal
Spherical
Other
If Pit/Vault/Cellar, Trench/Excavation, What Type:
Open on Top
Partially Enclosed
Totally Enclosed
Confined Space Material of Construction:
Concrete
Steel
Steel Mesh
Stainless Steel
Earth
Timber
Fiberglass/Resin
Other
Approximate Size & Configuration:
Length
Height
Width
Diameter
Depth
Approximate Volume of Space (cubic feet):
Entry Point Type:
Vertical
Horizontal
Other
Entry Point Size:
Height
Width
Diameter
Number of Entry Points/Manways:
Process Space/Equipment Contains:
Type of Product
Hazard of Material or Process in Space:
Flammable/Combustible Liquid or Gas
Toxic
Thermal (high or low temp)
Irritant
Corrosive/Reactive
Other Media and Reagent
Safety Data Sheet Available
Internal Mechanical/Structural Hazards or Obstructions:
Mixers/Agitators/Combs
Tubing
Structural Members
Flotation Devices
Cone Bottom
Anodes
Weirs/Trays
Other
External Mechanical/Structural Hazards or Obstructions:
Motor Drive Units
Other
Other Potential Hazards:
Engulfment
Entanglement
Other
Probable Atmospheric Hazards:
Oxygen Deficient/Enriched
Flammable
Hydrogen Sulfide (H2S)
Other
Type of Rescue Equipment Needed:
Lifeline (may entangle on equipment or in moving parts)
Retrieval Device
Fall Protection
Harness Wristlets/Anklets
Inpob/Davit
Ladder
Other
Rescue Team Needed:
Tier I (Non-Complex) Rescue Team
Tier II (Complex) Rescue Team
Reviewed By:
Reviewed By Email:
example@example.com
Title:
Reviewer Signature
Submit
Should be Empty: