Confined Space Survey Form

This form is also available in Adobe pdf format.

Confined Space Survey Form
Date of Survey: ___________________________________	Permit Required: Y N
Confined Space Number: ____________________________	Building Number: __________________________
Location of Space: ____________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Description of Space: _________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Possible Atmospheric Hazards: _________________________________________________________________________ ____________________________________________________________________________________________________
Possible Physical Hazards: _______________________________________________________________________________ ____________________________________________________________________________________________________
Orientation of Space: Horizontal / Vertical
Unusual Hazards: ____________________________________________________________________________________ ____________________________________________________________________________________________________
Reasons for Entry: ____________________________________________________________________________________
Typical Entry Activities: ________________________________________________________________________________ ____________________________________________________________________________________________________
Who Usually Enters Space: _____________________________________________________________________________ ____________________________________________________________________________________________________
Frequency of Entry: _________________________________________________________________
Number of Entry Points: _____________________________________________________________
Potential Energy Hazards Connected to Space (Mechanical, Electrical, Steam, Etc.): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
Survey Completed By: ______________________________	Date: __________________________
Telephone Number: _________________________________	Used for information clarification only.
Department: ______________________________________________________________________________

Comments:___________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Rev. 2/97

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