Confined Space Evaluation & Information Form

Confined Space Evaluation & Information Form

ReconAfrica
Date:

MonthDayYear
Date
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:

Tank/VesselPit/Vault/CellarTrench/ExcavationOther
If Tank/Vessel, What Type?

VerticalHorizontalSphericalOther
If Pit/Vault/Cellar, Trench/Excavation, What Type:

Open on TopPartially EnclosedTotally Enclosed
Confined Space Material of Construction:

ConcreteSteelSteel MeshStainless SteelEarthTimberFiberglass/ResinOther

Approximate Size & Configuration:

Entry Point Size:

Number of Entry Points/Manways:
Process Space/Equipment Contains:
Type of Product
Hazard of Material or Process in Space:

Flammable/Combustible Liquid or GasToxicThermal (high or low temp)IrritantCorrosive/ReactiveOther Media and ReagentSafety Data Sheet Available
Internal Mechanical/Structural Hazards or Obstructions:

Mixers/Agitators/CombsTubingStructural MembersFlotation DevicesCone BottomAnodesWeirs/TraysOther
External Mechanical/Structural Hazards or Obstructions:

Motor Drive UnitsOther
Other Potential Hazards:

EngulfmentEntanglementOther
Probable Atmospheric Hazards:

Oxygen Deficient/EnrichedFlammableHydrogen Sulfide (H2S)Other
Type of Rescue Equipment Needed:

Lifeline (may entangle on equipment or in moving parts)Retrieval DeviceFall ProtectionHarness Wristlets/AnkletsInpob/DavitLadderOther
Rescue Team Needed:

Tier I (Non-Complex) Rescue TeamTier II (Complex) Rescue Team
Reviewed By:
Reviewed By Email:
example@example.com
Title:
Reviewer Signature

Clear
Should be Empty: