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CONFINED SPACE ENTRY FORM
NOTE TO ENTRY SUPERVISOR: Starting at the top of form, document your process by marking the appropriate check box and initialing. Once complete, turn in to HBI project supt., or his designee, for review and approval. Form to be filed at jobsite.
Time
Hours
:
Minutes
AM
PM
AM/PM
Date
MM slash DD slash YYYY
Entry Supervisor Name
First
Last
Job Site
Area
Is the space large enough and so configured that an employee can bodily enter it and perform work?
(Required)
Yes
No
Initial
Does the space have a limited or restricted means of access and egress?
(Required)
Yes
No
Initial
Is the space designed for continuous human occupancy?
(Required)
Yes
No
Initial
This IS NOT a Confined Space
Supervisor
This IS a Confined Space
Does the space contain material that has the potential to engulf an entrant?
(Required)
Yes
No
Does the space have an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor that slopes downward and tapers to a small cross-section?
(Required)
Yes
No
This is a CONFINED SPACE
Does this space contain any other recognized serious safety or health hazards (i.e. exposed energized electrical, live open piping/storm/sewer, mech. paddles/mixers or other forms of hazardous energy)?
(Required)
Yes
No
This is a CONFINED SPACE
Can physical hazards be eliminated from outside the confined space (i.e. lockout/tagout, blocking, blinding)?
(Required)
Yes
No
This is a CONFINED SPACE
Does the space contain, or have the potential to contain, a hazardous atmosphere due to existing condition or scope of work being performed?
(Required)
Yes
No
This is a CONFINED SPACE
Is continuous forced air ventilation and continuous air monitoring alone sufficient to maintain the space safe for entry?
(Required)
Yes
No
This is a Permit-Required Confined Space using Alternative Methods
(Complete the CSE Permit using alternative methods prior to entry)
I attest to the accuracy of this document and understand to complete the permit (alternate conditions) on the following page
Yes
Supervisor
This is a Permit-Required Confined Space
(Complete the CSE Permit prior to entry)
I attest to the accuracy of this document and understand to complete the permit on the following page
Yes
Supervisor
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