Confined Space Test Page HBI – Confined Space Entry Form Step 1 of 10 – Job Info 0% 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 InitialDoes the space have a limited or restricted means of access and egress?(Required) Yes No InitialIs 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
