Confined Space Survey Form - Duke University
|Date of Survey |Confined Space # |Permit Required? |Yes ο No ο |
|Location of Space (include Building # of closest building) |
| |
|Description of Space, including dimensions |
| |
|Confined Space if 1 – 3 below are ALL “Yes” |Permit Required Confined Space if ANY below are “Yes” |
|Can be bodily entered? |Yes ο |No ο |Potential hazardous atmosphere? (See A) |Yes ο |No ο |
|Limited or restricted entry? |Yes ο |No ο |Potential for engulfment? (See B) |Yes ο |No ο |
|Not designed for continuous human occupancy? |
|Possible Content/Engulfment Hazards: Previous contents ο Content fill or removal ο Shifting contents ο Dust ο |
|Configuration of Space: Interior shape & slope ο Low overhead clearance ο Drop offs ο |
|Complex layout ο Stability ο Structural integrity ο |
|Comments: |
|Potential Energy: Electrical ο Hydraulic ο Pneumatic ο Mechanical ο Fire control system ο Steam ο |
|Environment in the Space |
|Slippery Surface ο Ambient temperature high or low ο Surface temperatures high or low ο Noise ο |
|Comments: |
|Other Hazards: Animals ο Insects ο Biological organisms ο Non-ionizing radiation ο Ionizing radiation ο |
|Comments: |
|External Hazards that could impact safety in space: Traffic ο Machinery ο Equipment ο Processes ο Terrain ο |
|Comments: |
|If hazard evaluation determines this to be a PRCS, is space posted with signs or secured/locked indicating PRCS? |
|Reasons for entering space & typical activities |
| |
|Who usually enters space? Maintenance ο Production ο Contractors ο Other ο |
|Frequency of entry |Number of entry points # |
|External connections to space |
|Eligible for Alternate Procedure? |
|(if Hazardous Atmosphere is ONLY hazard) |
|Survey completed by |
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