Confined Space Information Gathering

This Confined Space Hazard Assessment Questionnaire is designed to help us understand the specific characteristics, hazards, and controls associated with your confined space work.

By providing detailed information about the space layout, entry and rescue methods, atmospheric conditions, adjacent piping, flow bypass plans, and the use of products, we can create a thorough and compliant hazard assessment and entry procedure.

Your input allows us to develop a safe, effective, and site-specific confined space plan tailored to your project.

SECTION 1 – GENERAL INFORMATION

Date

Company Name

Name Of Person Completing This Form

Best Email

Best Phone Number

Site Name

Confined Space Location (Address)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Anticipated Date Of Entry

Duration Of The Entry

Is A Visit By A Qualified Person To Site Required?

YES
NO
NOT SURE

Please Describe The Scope Of Work

SECTION 2 – PHYSICAL CHARACTERISTICS OF THE SPACE

Type Of Structure / Confined Space

Describe Other Please

Shape Of Confined Space

Rectangular, Box or Cube Shaped
Round, Barrel, Cylinder
Other

Describe Other Please

Dimensions (Length, Width, Height in meters or feet)

What Materials Is The Confined Space Made Of?

Is The Structure

Entry/Exit Points: How Many, What shape, Dimensions , Location In Relation To The Confined Space, Fixed or Permanent Ladder, Secured, etc.?

Internal Features, Equipment, Materials, etc.

Age Of The Confined Space (If Known)

Is There Adjacent Piping In The Confined Space?, How Many inlet and outlet pipes? what diameter, etc.

Will Isolation and Lockout be Applied?, Please Describe

Please Upload Pictures, Videos, Drawings or Any other Document That You Think Would Be Useful To Develop Documentation

Click or drag files to this area to upload. You can upload up to 10 files.

SECTION 3 – ATMOSPHERIC CONDITIONS

Atmospheric Testing Performed? Is There A History?

YES
NO
UNKNOWN

Can You Share The History?

YES
NO

Please Upload The History If You Are Able

Click or drag a file to this area to upload.

Known Or Potential Contaminants

SECTION 4 – WORK ACTIVITIES & HAZARDS

Tasks To Be Performed Inside The Confined Space

Are there adjacent or connected pipes?

Is there a plan for isolating adjacent piping?

Will a bypass system be used to reroute flow?

Will pneumatic plugs (pigs, test balls) be used to block the flow?

WIll Tidal Influence Affect The Flow Of Liquids In The Confined Space?

Will products be used that contain the following?

Please Upload The SDS if Available

Click or drag files to this area to upload. You can upload up to 10 files.

Checkboxes

Describe Other

Potential For Hazardous Materials To Be Present?

Describe Other

Is There Anything Else You Would Like To Share About your Confined Space?