"Confined Space Hazard Assessment Form - University of Guelph"

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Appendix B
CONFINED SPACE HAZARD ASSESSMENT
Confined Space Name/Location/Identification #:
Performed by:
Date:
Contents or use of Space: __________________________________________
Expected atmospheric hazard: ______________________________________
Hazard measured by: O Air monitoring O Other means ___________________
O Air monitor sensor required ______________________
1) Access to the Confined Space
Entrance/Exit Accessibility and Configuration (check a where applicable)
Entrance/Exit easily accessible O Yes
O No
Describe entrance/exit:
Location: O Top O Bottom O Side
Type: O Round O Oval
O Square O Other: _________________________________
Size (Diameter, etc.): _______________________________________________________
Vertical Entry/Exit O Yes
O No
O Stairs O Fixed Ladder O Portable Ladder O Other: ___________________________
Condition: ________________________________________________________________
Distance down/in: __________________________________________________________
Tripod to be used: O Yes
O No
Limitations: __________________________________
Other Method: O Yes
O No
Limitations: _____________________________________
Horizontal Entry/Exit O Yes
O No
Elevated entry/exit O Yes
O No
__________________________________________
Work platform provided for elevated entry O Yes
O No
O Not necessary __________
Distance in: _______________________________________________________________
Retrieval device to be used: __________________________________________________
Limitations: _______________________________________________________________
2) Internal Configuration and Features of Confined Space (check a where applicable)
Ceiling inside space:
Low ceilings O Yes
O No _________________________________________________
O Walk in
O Erect
O Stooped
O Crawl in
O Hands and Knees
O Stomach/Back
Head Hazards O Yes
O No _______________________________________________
Footing inside space:
O Flat surface
O Sloping Surface
O Uneven surface
O Slippery surface
O Cramped
O Climb/step over obstructions: _______________________________________________
O Tripping Hazards O Yes
O No __________________________________________
Appendix B
CONFINED SPACE HAZARD ASSESSMENT
Confined Space Name/Location/Identification #:
Performed by:
Date:
Contents or use of Space: __________________________________________
Expected atmospheric hazard: ______________________________________
Hazard measured by: O Air monitoring O Other means ___________________
O Air monitor sensor required ______________________
1) Access to the Confined Space
Entrance/Exit Accessibility and Configuration (check a where applicable)
Entrance/Exit easily accessible O Yes
O No
Describe entrance/exit:
Location: O Top O Bottom O Side
Type: O Round O Oval
O Square O Other: _________________________________
Size (Diameter, etc.): _______________________________________________________
Vertical Entry/Exit O Yes
O No
O Stairs O Fixed Ladder O Portable Ladder O Other: ___________________________
Condition: ________________________________________________________________
Distance down/in: __________________________________________________________
Tripod to be used: O Yes
O No
Limitations: __________________________________
Other Method: O Yes
O No
Limitations: _____________________________________
Horizontal Entry/Exit O Yes
O No
Elevated entry/exit O Yes
O No
__________________________________________
Work platform provided for elevated entry O Yes
O No
O Not necessary __________
Distance in: _______________________________________________________________
Retrieval device to be used: __________________________________________________
Limitations: _______________________________________________________________
2) Internal Configuration and Features of Confined Space (check a where applicable)
Ceiling inside space:
Low ceilings O Yes
O No _________________________________________________
O Walk in
O Erect
O Stooped
O Crawl in
O Hands and Knees
O Stomach/Back
Head Hazards O Yes
O No _______________________________________________
Footing inside space:
O Flat surface
O Sloping Surface
O Uneven surface
O Slippery surface
O Cramped
O Climb/step over obstructions: _______________________________________________
O Tripping Hazards O Yes
O No __________________________________________
Other internal features of space:
Poor lighting O Yes
O No ________________________________________________
Sharp objects O Yes
O No _______________________________________________
Spilled Chemicals O Yes
O No ____________________________________________
Rusty Surfaces O Yes
O No ______________________________________________
Animal/Insects O Yes
O No ______________________________________________
Chemical coated walls/surfaces O Yes
O No _________________________________
Biological residue/slime O Yes
O No _______________________________________
Liquids on floor/walking surfaces (standing water) O Yes
O No ___________________
Pipelines going through the space O Yes
O No _______________________________
Materials in pipes/lines: _____________________________________________________
Pipes with mechanical joints (flanges, valves) inside space: _________________________
Site Support:
O Grounding point available O Yes
O No
O NA _____________________________
O Electrical services present O Yes
O No
O NA ____________________________
O Anchorage points for rescue O Yes
O No
O NA ___________________________
3) Electrical Hazards O Yes
O No
Possible contact with energized conductors O Yes
O No _________________________
_________________________________________________________________________
Lockout procedures required O Yes
O No
Lockout points identified O Yes
O NA
4) Mechanical Hazards O Yes
O No
Moving/Rotating belts, blades, gears, pinch points, etc. O Yes
O No _______________
_________________________________________________________________________
Lockout procedures required O Yes
O No
Lockout points identified O Yes
O NA
5) Hydraulic/Pneumatic Hazards O Yes O No
If “Yes” continue; if “No” proceed to #10:
Hydraulic O Yes
O No ___________________________________________________
Pneumatic O Yes
O No __________________________________________________
6) Engulfment Hazards O Yes
O No
O Liquid
O Powder/Grains
O Sludge/Sewage ________________________________
7) External Hazards O Yes
O No
O Traffic hazard
O Parking Lot (loading area/parking spaces in vicinity)
O Precipitation
O Overhead electrical wires
O Spill or possibility of objects falling into opening
8) Other Considerations: Hot Work
O Yes
O No
If “Yes” continue below; if “No” proceed to #13:
O Welding
O Cutting
O Grinding
O Power Tools
O Other _________________
9) Other Considerations: Ventilation
O Space has configuration that will hamper ventilation/purging
O Convoluted space
O Large volume
O Other _________________________
O Additional opening(s) _____________________________________________________
10) Other Considerations: Communications
O Entrants can be visually observed by attendant
O Yes
O No
O Voice only adequate
O Visual hand signal adequate
O Internal telephone available
O Cell Phone required
O Radio required
O Intercom
O Rope signal
11) Adverse Temperatures
O Yes
O No
Heat Stress
Hot pipes/lines O Yes
O No ______________________________________________
Steam lines O Yes
O No _________________________________________________
Direct sun exposure O Yes
O No __________ Other O Yes
O No ____________
Cold Stress
Coolant lines O Yes
O No ________________________________________________
Ice formation O Yes
O No ________________________________________________
Other O Yes
O No ______________________________________________________
12) Noise/Vibration O Yes
O No
:
Noise
Traffic O Yes
O No
Other: ______________________________________________
Annoyance O Yes
O No
Communications Interference O Yes
O No
Vibration
Discomfort O Yes
O No
Other: __________________________________________
13) Chemical Hazards O Yes
O No
Chemicals present: O Pipes/lines
O Closed tank(s)
O Open tank(s)
O Spilled
Accumulation of O flammable/ O combustible/ O explosive agents O Yes
O No
Chemical Exposure Potential: ____________________ MSDSs available O Yes
O No
14) Radiation Hazards O Yes
O No
Ionizing:
Radioisotopes O Yes
O No _______________________________________________
Sealed Sources O Yes
O No ______________________________________________
Non-Ionizing:
Micro-wave O Yes
O No
Radiofrequency O Yes
O No
Other: _______________
Laser(s) O Yes
O No ____________________________________________________
15) Other Considerations
_________________________________________________________________________
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