CONFINED SPACE SELF-INSPECTION CHECKLIST
The following checklist should be used on an annual basis to monitor the effectiveness of the
Confined Space Operations Program. After completing the checklist, it should be dated, signed,
and submitted, along with plans for corrections, to the Associate Vice Chancellor Administrative
Services. Upon acceptance by the Associate Vice Chancellor Administrative Services, the
evaluation checklist should be maintained in the universities files in accordance with UW Oshkosh record retention policy requirements.
PROGRAM ADMINISTRATION
Is there a written document which establishes the confined space program and assigns program
responsibility, accountability, and authority?
YES NO
Comment:
Is program responsibility vested in a trained individual who is knowledgeable and who can
administer all aspects of the program within the campus?
YES NO
Comment:
Does a system exist to identify regulatory requirements for confined space entry?
YES NO
Comment:
Are copies of these regulations available at the University?
YES NO
Comment:
Are there written procedures/statements covering the various
aspects of the confined space program, including:

Duties of administrator, facility leaders, confined space entry permit authorizers, and
other persons with designated duties under the confined space program
YES NO
Comment:

Procedures for the assessment of spaces, identification of their hazards, and the
development of appropriate entry procedures
YES NO
Comment:

The establishment of a system to ensure that confined space entry is performed only in
accordance with the entry procedure and permit requirements
YES NO
Comment:

Labeling of confined spaces
YES NO
Comment:

Employee training programs appropriate for the assigned duties
YES NO
Comment:

Inspection, maintenance, storage, and repair of entry equipment
YES NO
Comment:

Periodic audits of confined spaced operations by leaders
YES
NO
Comment:

Entry by personnel of other employers
YES NO
Comment:

Annual program audit, including corrective actions
YES NO
Comment:

Has the university taken effective action to prevent unauthorized entry into confined
spaces?
YES NO
Comment:

What is the date of the most recent annual audit?
YES NO
Comment:

Was a report covering the annual audit provided to the Associate Vice Chancellor
Administrative Services?
YES NO
Comment:

Were the recommendations of that audit implemented?
YES NO
Comment:
CONFINED SPACE SURVEY
Has a systematic survey been performed to identify all confined spaces within the university?
YES NO
Comment:
Is the survey repeated on a periodic basis?
YES NO
Comment:
Was a checklist or other standardized form used for the survey?
YES NO
Comment:
Are procedures in place for the assessment of all new facilities and equipment for the existence
of confined spaces?
YES NO
Comment:
Are all confined spaces labeled?
YES NO
Comment:
HAZARD ASSESSMENT
Has a hazard assessment been conducted for each space identified as a confined space?
YES NO
Comment:
Was a standardized form used for this assessment?
YES
NO
Comment:
Has a task inventory been compiled for each space?
YES NO
Comment:
ENTRY PROCEDURES
Have entry procedures and permits been developed for each confined space?
YES NO
Comment:
Are entry procedures and permits specific to the hazards of the confined space?
YES NO
Comment:
Do the entry procedure identify all pre-entry preparations that must be completed prior to entry?
YES NO
Comment:
Do the entry procedures and permits identify the specific tasks that may be performed during
the entry?
YES NO
Comment:
Are special precautions established for tasks performed in the confined space which may create
additional hazards, such as hot work, etc.?
YES NO
Comment:
Are the entry procedures and permits reviewed annually?
YES NO
Comment:
Is the entry procedure reviewed prior to entry into the space?
YES NO
Comment:
Review a representative number of completed permit forms:
of
have been completed properly. _____ %
Comment:
ENTRY EQUIPMENT
Has the necessary entry equipment been identified and provided?

Atmospheric testing and calibration equipment?
YES NO
Comment:

Atmosphere control (ventilation) equipment?
YES NO
Comment:

Personal Protective equipment?
YES NO
Comment:

Communications equipment?
YES NO
Comment:

Electrical equipment?
YES NO
Comment:

Emergency and rescue equipment?
YES NO
Comment:

Is there a program for the periodic inspection of the equipment?
YES NO
Comment:

Is the equipment properly maintained?
YES NO
Comment:
THE ENTRY TEAM
Are entry team members designated?
YES NO
Comment:
Have the duties of the team members been established?
YES NO
Comment:
Has a training program been established to ensure that each team member has the requisite
knowledge and skills for safe entry?
YES NO
Comment:
Has First Aid and CPR training been provided to the members of the entry team?
YES NO
Comment:
Do the team members get the opportunity to practice their skills outside of actual entry?
YES NO
Comment:
Does the training program include a demonstration by the team members of their ability to
perform the tasks?
YES NO
Comment:
EMERGENCY PREPAREDNESS
Has an emergency response plan been established for confined space rescue?
YES NO
Comment:
Has a rescue team been identified?
YES NO
Comment:
If the rescue team is a team of UW - Oshkosh employees:

Has the rescue team been properly equipped and trained to perform entry rescue in all
of the universities confined spaces?
YES NO
Comment:

Does the rescue team conduct periodic drills?
YES NO
Comment:
If the rescue team is an organization from outside of UW - Oshkosh:

Is the response organization designated in writing?
YES NO
Comment:

Has the university evaluated the capability of the rescue service to provide a timely
response?
YES NO
Comment:

Has the university evaluated the training and equipment of the rescue organization?
YES NO
Comment:

Has the rescue service evaluated the confined spaces present at the university in order
to pre-plan the necessary rescue response?
YES NO
Comment:

Has the rescue service conducted drills at the university?
YES NO
Comment:
CORRECTIVE ACTION
1.
2.
3.
4.
ASSESS DATE:
ASSESSOR:
BY WHOM
BY WHEN
DATE
COMPLETED