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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