CONFINED SPACE INFORMATION GATHERING – BELL PHILLIPS SAFETY GROUP

The 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

Email

Phone

Confined Space Location

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Anticipated Entry Date(s)

Duration Of The Entry

Visit Required

Work Description / Scope

SECTION 2 – PHYSICAL CHARACTERISTICS OF THE SPACE

Type of Structure

Describe Other Please

Shape Of Confined Space

Rectangular
Round/Barrel
Other

Describe Other Please

What Materials Is The Confined Space Made Of?

inside Are would

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

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.

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 7 files.

SECTION 3 – ATMOSPHERIC CONDITIONS

Atmospheric Testing Performed? Is There A History?

Yes
No

Can You Share The History?

Known or potential contaminants

Chemical or biological residues

SECTION 4 – WORK ACTIVITIES & HAZARDS

Tasks to be performed inside the 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 products be used that contain the following?

SDS Available?

Yes
No

Please upload SDS files if you have them

Click or drag a file to this area to upload.

Application method

Describe Other

Is there anything else you would like to share about your confined space?