Contents

H&S Self-Assessment Checklist: CONFINED-SPACE ENTRY
This checklist is provided as a method of verifying compliance with the OSHA confined-space entry standard. It shall be used at
locations where CH2M HILL employees enter confined spaces, or are required to perform oversight of subcontractor personnel
entering confined spaces, or both.
CH2M HILL staff shall not direct the means and methods of subcontractor confined space operations nor direct the details of
corrective actions. The subcontractor must determine how to correct deficiencies and CH2M HILL staff must carefully rely on
their expertise. Items considered to be imminently dangerous (possibility of serious injury or death) must be corrected
immediately or all exposed personnel must be removed from the hazard until corrected.
Completed checklists must be sent to the appropriate Regional Health and Safety Program Manager (RHSPM) for review.
Project Name: ______________________________________________________ Project No.: _____________________
Location: ______________________________________________________ PM: ____________________________________
Auditor: ____________________________________ Title: _________________________________ Date: ________________
This specific checklist has been completed to (check only one of the boxes below):
Evaluate CH2M HILL compliance with its confined-space entry program (SOP HS-17)
Evaluate a CH2M HILL subcontractor’s compliance with its confined-space entry program
Subcontractor’s Name: ________________________________________________________________________________
• Check “Yes” if an assessment item is complete or correct.
• Check “No” if an item is incomplete or deficient. Section 2 must be completed for all items checked “No.”
• Check “N/A” if an item is not applicable.
• Check “N/O” if an item is applicable but was not observed during the assessment.
Numbers in parentheses indicate where a description of this assessment item can be found in Standard of Practice HS-17.
CONFINED SPACE EVALUATION (6.1)
SECTION 1 Yes No N/A N/O
1. Staff informed of location and hazards of existing confined spaces (danger signs, verbal)
2. Determination made that work can not be completed without entering the confined space
3. Information obtained regarding the space (blue prints, potential hazards, energy sources)
4. Spaces classified as permit-required, alternative procedure, or nonpermit confined spaces
TRAINING (6.2)
5. Entrants, Attendants, and Entry Supervisor have completed confined-space entry training
6. Employees performing lockout/tagout procedures have completed LOTO training
7. Employees required to wear respirators have completed respiratory protection training
CONFINED-SPACE ENTRY (6.3)
8. Completed permit or certificate posted at space entrance
9. Preentry briefing conducted
10. Entrants/Attendants verify that entry supervisor has authorized entry
11. Entrants/Attendants verify that all requirements of the permit or certificate have been satisfied
12. Atmospheric monitoring is conducted at frequency provided on the permit or certificate
13. Entry not permitted if an atmospheric hazard is detected above acceptable safe levels
14. Entrants evacuate space upon orders of the attendant or entry supervisor,
when an alarm is sounded, or when a prohibited condition or dangerous
situation is recognized
15. Entrants/Attendant informs entry supervisor of hazards confronted or created in the space
or any problems encountered during entry.
16. Entry supervisor informs the owner of such issues in item 15 above
17. Ladder or other safe means of access provided if greater than 4 feet deep.
H&S Self-Assessment Checklist: CONFINED-SPACE ENTRY (Page 2 of 4)
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