Confined Space Safety Assessment
Please complete the following safety assessment before entering confined spaces.
Assessor Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Confined Space
*
Type of Confined Space
*
Please Select
Tank
Silo
Manhole
Tunnel
Vault
Other
Hazard Identification
*
Oxygen Deficiency
Flammable Gases
Toxic Gases
Engulfment Hazard
Electrical Hazard
Mechanical Hazard
Temperature Extremes
Noise
Other
Safety Equipment Available
*
Safety Measures Taken
*
Is a Confined Space Entry Permit Issued?
*
Yes
No
Supervisor Name
First Name
Last Name
Supervisor Signature
Submit
Should be Empty: