EHS | Phone: 703.993.8448 | Fax: 703.993.8996 | safety@gmu.edu | Last Updated: 10/2014 PAGE 1 of 2

Alternate Confined Space Entry Procedure Certification Form

Location (Building / Room)SECTION 2 - CONFINED SPACE INFORMATION

Please provide brief description of the confined space:

SECTION 1 - ENTRY SUPERVISOR’S INFORMATION

Environmental Health & Safety Office

Last Name

Department

First Name Phone Email

Please fill out this form and email or fax the completed form to Environmental Health & Safety Office (EHS).

Yes NoThe only hazard within the confined space is atmospheric. No other hazards exist. Continuous forced-air ventilation alone is sufficient to eliminate the atmospheric hazard. Monitoring and inspections verify that no other hazardous conditions exist. Conditions that make it unsafe to remove entrance covers have been eliminated prior to removing the cover.Entrances and openings are guarded to protect employees from falls and foreign objects. If entry is required to conduct tests or inspections to determine the presence of hazards, permit-required confined spaced procedures must be followed.

SECTION 3 - ALTERNATE ENTRY PROCEDURE CONDITIONS

All of the following conditions must be satisfied to use alternate entry procedure.

SECTION 4 - CONFINED SPACE MONITORING RESULTS

Monitoring results prior to forced-air-ventilation:

Percent Oxygen

Carbon Monoxide

10% of Lower Explosive Limit Toxic (Name)

Toxic Permissible Exposure Limit

(PEL)

Monitoring results with forced-air-ventilation:

Percent Oxygen

Carbon Monoxide

10% of Lower Explosive Limit Toxic (Name)

Toxic Permissible Exposure Limit

(PEL)

EHS | Phone: 703.993.8448 | Fax: 703.993.8996 | safety@gmu.edu | Last Updated: 10/2014 PAGE 2 of 2

Entry Supervisor’s Signature:

Entrant’s Signature:

Date:

Date:

EHS Signature: Date: