University of Kentucky
CONFINED SPACE EVALUATION - ENTRY PERMIT SYSTEM
PART 2: EVALUATION FORM

PART 2 - PAGE 1

Entry Date: ___________________________ Entry Time: ___________________________

Entry team Supervisor's Name: _________________________________________________

Entry team Attendant's Name: __________________________________________________

Location of Work to be Performed: ______________________________________________

Reason for Entering Confined Space: ____________________________________________

__________________________________________________________________________

POTENTIAL HAZARDS

____ Corrosive Materials
____ Flammable Materials
____ Inert Gases
____ Steam		 ____ Toxic Materials
____ Lack of Oxygen
____ Engulfment
____ Entrapment		 ____ Heat or Cold
____ Slip, Trip, Falls
____ Water
____ Live Energy Source
____ Other hazards _____________________________________________________________

ATMOSPHERIC TESTING

Equipment Calibration Type and S/N Date Time Calibrated By
_______________________________     /    /00 am/pm ______________________
_______________________________     /    /00 am/pm ______________________
_______________________________     /    /00 am/pm ______________________
 
Atmospheric Testing Location: _______________________________ By: ___________________
Date/Time % Oxygen (19.5-23.5) %LEL (<10%LEL) Contaminant Concentration Exposure (PEL, TLV)
________ _____________ ______________ _______________ __________________
________ _____________ ______________ _______________ __________________
 

Atmospheric Testing Results Indicate:

____ Atmosphere is NOT Hazardous

____ Atmosphere is Hazardous (Complete Part 3)

____ Hazard Cannot be Eliminated (Complete Part 4)

____ Space Occupied-Evacuation Initiated Time: _______
(Cancel Permit)
Part 1 | Confined Space Program | Part 2-2