P&S Job Site Safety Inspection

Confined Space Pre-Entry Checklist

To be completed and submitted before entering into a Confined Space
Date*

MonthDayYear
Date
Supervisor*

Chris PettisCody ZimmermanEric OdonelJoe PerezJosh DiGulioKris GardnerMichael KovalPaul SchaiderSean SesherZach McCoyOther
Chris Pettis Projects
Cody Zimmerman Projects
Eric O' Donel Projects
Joe Perez Projects
Josh DiGulio Projects
Kris Gardner Projects
Michael Koval Projects
Paul Schaider Projects
Sean Sesher Projects
Zach McCoy Projects
Other Project (jobs that may not appear in the drop down menu above)
Select the employees that are on site:*
Other Employees on-site
Are there potential Confined Space issues on the project?*

YesNo
Test #1 - Does the space have the potential to contain a hazardous atmosphere?

YesNo
Test #2 - Does the space contain material with the potential to engulf someone who enters the space?

YesNo
Test #3 - Does the internal configuration of the space have inwardly converging walls or a floor that slopes downward and tapers to a smaller cross section?

YesNo
Test #4 - Does the space contain any other recognized serious safety or health hazards?

YesNo
Warning - This is a Permit Required Confined Space. Do not enter the space!

Contact your Supervisor and the Safety Manager for further directions
The Alternative Entry Procedure is Acceptable

Complete the following items before entering the space.
Description of the Space:*
Description of the Work and Tasks that will be performed:*
Who will be responsible for performing the periodic testing:*

First NameLast Name
Is a hazardous atmosphere the only serious hazard of concern?*
Warning - If there are other serious hazards, this is a Permit Required Confined Space. Do not enter the space!

Contact your Supervisor and the Safety Manager for further directions
Does an inspection of the interior have to be conducted to see if a serious hazard exists?*
Warning - If an inspection of the interior is required to determine if there are any serious hazards, this is a Permit Required Confined Space. Do not enter the space!

Contact your Supervisor and the Safety Manager for further directions
If a cover is present, is it safe to remove the cover?*
Warning - Do not proceed until it is safe to remove the cover!

Contact your Supervisor and the Safety Manager for further directions
Is the opening to the Space properly guarded?*
Warning - Do not proceed until the opening is properly guarded!

Contact your Supervisor and the Safety Manager for further directions
Will frequent or periodic atmospheric testing be performed?*
Warning - Do not enter the Space unless the periodic testing occurs!

Contact your Supervisor and the Safety Manager for further directions
Is the atmospheric testing equipment calibrated?*
Date of Calibration*

MonthDayYear
Date
Warning - Do not enter the Space until you have tester that has been calibrated properly!

Contact your Supervisor and the Safety Manager for further directions
Have all employees, that may enter the Space, been instructed to evacuate the space immediately if a hazardous atmosphere is detected?*
Warning - Instruct the other employees on site of the requirement to evacuate the Space if a hazardous atmosphere is detected and to not re-enter the space until it has been re-evaulated and cleared by a qualified personnel.

Once, everyone on site has been instructed properly, the answer above can be changed to "Yes"
Calculations

The following calculations are based upon Utilizing an Air Systems International SVF-25ACAN (similar to the image to the left). If you need a different Ventilation kit or setup, contact your Supervisor and/or the Safety Manager before proceeding further.
What is the shape of the Space*
What is the distance, in feet, of the Height (H) of the square (or rectangle) Space?*
Feet
What is the distance, in feet, of the Width (W) of the square (or rectangle) Space?*
Feet
What is the distance, in feet, of the Depth (D) of the square (or rectangle) Space?*
Feet
The area of the Space is
Cubic Feet
Blowers required (with 15' of hose and one 90 degree fitting):
What is the distance, in feet, of the Depth (h) of the cylindrical Space?*
Feet
What is the distance, in feet, across (d) of the cylindrical Space?*
Feet
The area of the Space is:
Cubic Feet
Blowers required (with 15' of hose and one 90 degree fitting):
Other than blowers and LEL Meters, are there any other safety devices or PPE required to ensure the safety of the entrant(s):*
Are all of the required number of blowers, the LEL Meters, and the other necessary safety items (from the checklist above) in place:*
Warning - Do not enter the Space until you have all of the proper safety devices in place!

Contact your Supervisor and the Safety Manager for further directions
Foreman/Leadman*

First NameLast Name
Email
example@example.com
Foreman/Leadman Signature*

Clear
Should be Empty:

Confined Space Pre-Entry Checklist

Warning - This is a Permit Required Confined Space. Do not enter the space!

The Alternative Entry Procedure is Acceptable

Warning - If there are other serious hazards, this is a Permit Required Confined Space. Do not enter the space!

Warning - If an inspection of the interior is required to determine if there are any serious hazards, this is a Permit Required Confined Space. Do not enter the space!

Warning - Do not proceed until it is safe to remove the cover!

Warning - Do not proceed until the opening is properly guarded!

Warning - Do not enter the Space unless the periodic testing occurs!

Warning - Do not enter the Space until you have tester that has been calibrated properly!

Warning - Instruct the other employees on site of the requirement to evacuate the Space if a hazardous atmosphere is detected and to not re-enter the space until it has been re-evaulated and cleared by a qualified personnel.

Calculations

Warning - Do not enter the Space until you have all of the proper safety devices in place!