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

PART 2 - PAGE 2

Hazard Evaluation Indicates:
_____ No Potential Hazard - Confined Space is Classified as a NPCS
_____ Hazard or Potential Hazard - Confined Space is Classified as a PRCS (Complete Part 2)

PERSONAL PROTECTIVE - SAFETY EQUIPMENT NEEDED
___ Barricades
___ Mech. Lifting Eqmt.
___ Coveralls
___ Gloves
___ Hearing Protection		 ___ Communication Eqmt.
___ Rescue Gear
___ Fall Protection
___ Safety Shoes
___ Manhole ring protector		 ___ Safety Harness
___ Flashlight
___ Hard Hat
___ Eye Protection
___ Ventilation gear

Other ________________________________________________________________________

CONFINED SPACE PREPARATION
Atmosphere is to be Tested:
___ Continuously
___ Periodically for: ____________
___ Other ____________________		 Forced Ventilation to be Used
___ Continuously
___ Periodically for: ____________
___ Other ____________________
Are all valves, switches, operating mechanisms, and energy sources locked or tagged out?
Y
N/A
Is vessel drained/flushed/neutralized?
Y
N/A
Is vessel space cleaned/purged?
Y
N/A
Are lines to vessel blanked or misaligned?
Y
N/A

PRE-ENTRY BRIEFING
Have all employees been adequately trained?
Y
N/A
Has emergency rescue been explained/established?
Y
N/A
Describe means of rescue: ______________________________________________
_____________________________________________________________________
Have the hazards of the work been explained?
Y
N/A
Has an attendant been designated?
Y
N/A
What is the name of the designated attendant? _______________________________________
Describe type of communication established _________________________________________
AUTHORIZED ENTRANTS
NAME TIME IN TIME OUT
____________________________________________________
__________
_________
____________________________________________________
__________
_________
____________________________________________________
__________
_________
Part 2-1 | Confined Space Program | Part 3