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APPENDIX C CONFINED SPACE EVALUATION FORM SPACE LOCATION: ________________________________________________________________ SPACE DESCRIPTION: ______________________________________________________________ Complete this form for any space which may be considered a confined space. A confined space is defined as having those all characteristics listed in #1 through #3 below. YES NO 1. Is the space large enough and shaped so an employee can enter and work? YES NO 2. Does the space have a limited or restricted means for entry or exit? YES NO 3. Is the space NOT designed for continuous employee occupancy? If the answers to all questions #1 through #3 above are “YES”, then the space is a Confined Space. Continue with questions A through E below to determine if and what type of permit is required to enter. YES NO A. Does the space contain, or have the potential to contain, a hazardous atmosphere, i.e., oxygen deficiency, flammable vapors, toxic gases or dusts, etc., or pipes, ducts, vents or other entry points for potentially hazardous substances, or will volatile chemicals be used, or will painting or other work that could create a breathing hazard be performed? Specify potential or known hazards: ________________________________________ YES NO B. Does the space contain a material with the potential for engulfment of a worker, e.g., grain, sand or water? Specify potential or known hazards: ________________________________________ YES NO C. Does the space have an internal shape such that a worker could be trapped or suffocated by inwardly converging walls, floor or ceiling? Specify potential or known hazards: ________________________________________ YES NO D. Does the space contain other recognized safety or health hazards, such as: (check all that apply) ___ mechanical hazards; ___ exposed or vulnerable electrical wires or energized equipment; ___ gas or chemical lines ___ special hazards related to elevation or falling; or ___ temperature extremes/heat stress Specify potential or known hazards: ________________________________________ YES NO E. Will welding, cutting, torch work, or other hot work be performed? Specify potential or known hazards: ________________________________________ If you answered “NO” to all questions A through E, then the space is a Non-Permit Required Confined Space. If you answered “YES” to question A, then classify the Permit as either General or Hazardous, depending on the ability to adequately ventilate the space. If you answered “YES” to question B, C or D, then classify the Permit as a General if the hazards can be controlled. If you answered “YES” to question E, then classify the Permit as Hot Work & also issue a Hot Work Safety Permit. Name: ___________________________ Signature: __________________________________ Department: _________________________________________________________________ Refer questions to OSEH at 647-1142. UNIVERSITY OF MICHIGAN CONFINED SPACE ENTRY PERMIT (Valid for maximum of one eight (8) hour shift and to be posted at work site.) Type of Entry Permit (check one): General Hazardous* Hot Work** (* Contact OSEH 7-1142) (** Issue Hot Work Safety Permit) Name of Entry Supervisor: _________________________________ Employee No.: _______________________ Work to be Performed: ______________________________________Duration:___________________________ Location of Permitted Confined Space: ___________________________________________________________ Pre-Entry Briefing Conducted by:____________________________ __________________________________ (Print) (Signature) Authorized Entrant(s): ____________________________________ __________________________________ ____________________________________ __________________________________ (Name) (Employee Number) Attendant/Spotter Name: ___________________________________ __________________________________ (if required) (Name) (Employee Number) ** In case of emergency, Attendant will call UM DPS at 911 (from a campus phone) or on Radio Channel 1A ** Specific hazards which will be encountered (see reverse): ________________________________________________ __________________________________________________________________________________________ Hazard control methods to be used: ______________________________________________________________ ___________________________________________________________________________________________ Required equipment to be used: (inspected and operational) Personal Protective: (respirator, clothing, etc.) _______________________________________________ Air Monitoring: __________________________________________________________________ Retrieval / Rescue: _______________________________________________________________ Purge / Ventilation: _______________________________________________________________ Communication: _________________________________________________________________ Special Tools: (approved electrical equipment, non-sparking tools, etc.) _________________________________ Supplied Air / Self-Contained Respirators _____________________________________________ MONITORING RESULTS Date/Time Monitoring Performed By O2 (%) 19.5–23.5% LEL (%) < 10% H2S (ppm) <15ppm CO (ppm) <35ppm Other (specify) Sample Location This confined space has been evaluated in accordance with the confined space entry procedures. All persons participating in this confined space entry have been trained in confined space entry procedures. The creation or discovery of any work induced hazards or other unforeseen, actual, apparent or potential hazards, requires the space be re-evaluated, additional precautions taken, and a new permit issued, if appropriate. Hazardous entries must be reviewed and approved by OSEH (7-1142). Entry Supervisor Signature (Issued): ____________________________________ Date and Time: ______________ Entry Supervisor Signature (Closed): ____________________________________ Date and Time: ______________ OSEH Authorization (Hazardous Entry Only): ________________________________ Date and Time: ______________ Please return this form to OSEH: CSSB, 1239 Kipke Drive, Box 1010. Refer questions to OSEH at 647-1142. Original: 10/97; Revised: 03/07
