Confined Space Evaluation & Information Form

Confined Space Evaluation & Information Form

ReconAfrica
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Entry Supervisor:

First NameLast Name
Supervisor Email:
example@example.com
Lease/Location Name:
Location at Facility:
Specific Process Equipment Name & Number:
Type of Confined Space:

Other
If Tank/Vessel, What Type?

Other
If Pit/Vault/Cellar, Trench/Excavation, What Type:
Confined Space Material of Construction:

Other

Approximate Size & Configuration:

Rows
Length
Height
Width
Diameter
Depth

Approximate Volume of Space (cubic feet):
Entry Point Type:

Other

Entry Point Size:

Rows
Height
Width
Diameter

Number of Entry Points/Manways:
Process Space/Equipment Contains:
Type of Product
Hazard of Material or Process in Space:
Internal Mechanical/Structural Hazards or Obstructions:

Other
External Mechanical/Structural Hazards or Obstructions:

Other
Other Potential Hazards:

Other
Probable Atmospheric Hazards:

Other
Type of Rescue Equipment Needed:

Other
Rescue Team Needed:
Reviewed By:
Reviewed By Email:
example@example.com
Title:
Reviewer Signature
Should be Empty: