Department of Energy (DOE) OSH Technical Reference

Chapter 4 - Confined-Space Entry

Appendix A. - Confined-Space Preentry Checklist

Checklist must be filled out whenever workers enter a permit required space. A copy of the safe entry procedure must be available at the entry point to the confined space.

                                                        OK     Action Needed
Did you survey the surrounding area to show it to be   -----    -----------
free of hazards such as drifting vapors from tanks,
piping, or sewers?                                       

Does your knowledge of industrial or other discharges
indicate this area is likely to remain free of air
contaminants while occupied?                           -----    -----------

Are you certified in operation of the gas monitor to
be used?                                               -----    -----------

Has a gas monitor functional test been performed
this shift on the gas monitor to be used?              -----    -----------

Did you test the atmosphere of the confined space
prior to entry?                                        -----    ----------- 
    
    (a) Was oxygen content between 19.5 percent and
        23.5 percent ?                                 -----    -----------
      
    (b) Was flammable vapor less than 10 percent of
        LEL/LFL?                                       -----    -----------
      
    (c) Were tests for toxic materials less than
        TLV/PEL?                                       -----    -----------

Have all sources of hazards been isolated from the
confined space?                                        -----    -----------

    (a) Have all pipes been blanked?                   -----    -----------

    (b) Have electrical and mechanical hazards been
        locked and blocked?                            -----    -----------

Is all rescue equipment called out in the safe entry
procedure available outside the confined space?        -----    -----------

Will the atmosphere be continuously monitored while
the space is occupied, if required by entry
procedure?                                             -----    -----------

Have the facility emergency and rescue services
been notified that a confined space entry is about
to be made?                                            -----    ----------- 

NOTICE: If any of the above questions are answered "Action Needed," do not
enter the confined space until the conditions are corrected.

Supervisor/Lead Man ______________________________