Employer’s Name
4.8.2
Confined Space Safety Risk Assessment Form
CONFINED SPACE RISK ASSESSMENT FORM
CONFINED SPACE RISK ASSESSMENT
Risk Assessment Conducted By:
Date of Assessment:
Confined Space Location:
Time of Assessment:
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AM/PM
Description of Plant:
Description of Work:
Identification if a confined spaces
Yes
No
Potential hazards
1.
Is the space enclosed or partially enclosed?
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2.
It the space not designed or intended to be occupied by a person?
Is the space designed or intended to be at normal atmospheric
pressure while a person is in the space??
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Is the atmosphere in the confined space a concern?
1.
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Can machinery start while in the space?
2.
Is the space likely to pose a risk to health and safety from:
Can entanglement with machinery occur?
an atmosphere that does not have a safe oxygen level?
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Can liquid or steam flow (inrush) while in the space?
3.
contaminants including airborne gases, vapour and dusts?
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Is isolation a concern?
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Harmful concentrations of any airborne contaminants?
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Uncontrolled introduction of substances?
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Engulfment?
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Biological Hazards
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Mechanical Hazards
Potential hazards
Yes
No
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Electrical Hazards?
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Restricted entry or exit?
Skin contact with hazardous substances?
Harmful airborne contaminants?
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Noise?
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May have oxygen levels below 19.5%?
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Manual Tasks?
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Oxygen may be in excess?
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Radiation?
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May have hydrogen sulphide present?
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Environmental?
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Fire and Explosion?
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Hazards outside confined space?
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Engiulfment?
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Other?
Is the work area a confined space?
Yes
Gases carbon monoxide, carbon dioxide, methane gas
present?
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Note: A risk assessment MUST be completed for any YES answers (turn page to complete).
NOTE: Please maintain a copy of this record sheet.
No
Compiled: 10/2012
Revision No: 1 –
Employer’s Name
Confined Space Safety Risk Assessment Form
CONFINED SPACE RISK ASSESSMENT
Description of Hazard / Risk from any
‘Yes’ answers on the previous page
1.
3.
2.
4.
RISK ASSESSMENT
CONTROLS OPTIONS
YES
NO
ELIMINATE – Can the process be eliminated
completely?


SUBSTITUTE – Can the process be replaced
with a safer one?
If YES, Detail
Action:


Hazard 1
ISOLATE – Can the process or person be
isolated from risk?
If YES, Detail
Action:


Hazard 2
ENGINEER – Can the process be re-designed?
If YES, tick the options to be used:


Indicate the risk assessment consequences and
likelihood in the columns below.
(Example Consequence – Major
Likelihood – Unlikely – Risk Score H
Consequence
Likelihood
Risk Score
 Natural Ventilation
Hazards / Risks Associated
 Blower Fan
Hazard 3
ADMINISTRATION – Can we limit exposure to
the risk by:  job rotation  work procedure 
training

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Hazard 4
PPE – Can we use Personal Protective
Equipment?
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Code: E – Extreme Risk, H – High Risk, M – Moderate risk, L – Low risk
No.

Risk Level
Prior to
Control
Control Measures /
Corrective Action
Risk Level
After
Control
Implemented
Yes / No
Verification Corrective Action has been taken.
Competent Person Name:
Competent Person Signature:
Date:
Supervisor Name:
Supervisor Signature:
Date:
NOTE: Please maintain a copy of this record sheet.
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Compiled: 10/2012
Revision No: 1 –
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