Permit Request • CampusOptics

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Name* Required

Additional Location Details

Entry Details

Purpose of Entry/Description of Work* Required

Department Responsible* Required

Authorized Personnel

Entry Supervisor Name* Required

Attendant 1 Name* Required

Attendant 2 Name* Required

Authorized Entrants* Required

Hazards in Confined Space

Oxygen deficiency* Required

Flammable gases or vapors* Required

Toxic gases or vapors exceeding Permissible Exposure Limit (PEL)* Required

Mechanical* Required

Electrical* Required

Engulfment* Required

Materials harmful to skin* Required

Configuration of space could trap entrant* Required

Heavy/awkward/pressurized entry covers* Required

Slick or obstructed working surfaces/trip hazards* Required

Dust* Required

Noise* Required

Heat/cold* Required

Falling* Required

Asbestos* Required

Lead* Required

Radioactive residues/gases* Required

Other (specify)* Required

Mandatory Preparations

Fire department notified* Required

Completed

Copy of completed permit posted near confined space entry points* Required

Completed

Map of confined space entry points marked on permit to aid first responder notification and response* Required

Completed

Arrange for qualified Attendant(s) and Entrant(s)* Required

Completed

Employees involved informed of specific confined space hazards* Required

Completed

Employees involved have reviewed procedures outlines on confined space checklist/permit* Required

Completed

Communication devices checked for proper operation immediately prior to entry* Required

Completed

Preparations

Obtain & review appropriate Safety Data Sheets (attach copies of SDS to this permit)* Required

N/A
Required
Completed

Respirator users have been trained, cleared, and fit tested for the make/model/size of the respirator* Required

N/A
Required
Completed

Notify all contractors involved/affected* Required

N/A
Required
Completed

Specify contractors involved/affected.* Required

Staging area for materials/equipment determined* Required

N/A
Required
Completed

Cordon off area around confined space/protect area from materials falling into vertical opening* Required

N/A
Required
Completed

Transportation routes unobstructed for emergencies* Required

N/A
Required
Completed

Isolate pipes by blanking, double-valve & bleeding, or lockout/tagout* Required

N/A
Required
Completed

Lockout/tagout energy sources to which entrants are exposed* Required

N/A
Required
Completed

Eliminate conditions making it unsafe to remove/open entrance before opening* Required

N/A
Required
Completed

Drain, clean, wash, and/or purge space* Required

N/A
Required
Completed

If purging is required, specify time. * Required

Ventilation of space as required to provide fresh air* Required

N/A
Required
Completed

If ventilation is required, specify.* Required

Hot work checklist completed and attached* Required

N/A
Required
Completed

Other (specify)* Required

Mandatory Equipment

Full body harness with retrieval line for entrants, attached to mechanical device or fixed point outside the space* Required

Present

Communication device for Attendant (cell phone/radio for summoning rescuers)* Required

Present

Equipment Required for Safe Entry

Confined space air monitor (calibrated) - Oxygen/Flammability/Hydrogen Sulfide/Carbon Monoxide* Required

N/A
Required
Present

Additional air monitoring equipment (calibrated)* Required

N/A
Required
Present

If additional air monitoring equipment is required, specify.* Required

Tripod/retrieval winch equipment (required for vertical descents over 5 feet)* Required

N/A
Required
Present

Remote hook and extendible pole* Required

N/A
Required
Present

Fall protection lanyards or self retracting lifelines (required if there are fall hazards over 4 feet; only a self-retracting lifeline may be used if the attachment point is less than 18.5 feet from objects below)* Required

N/A
Required
Present

Ventilation equipment (e.g. forced air fans/"elephant trunks")* Required

N/A
Required
Present

Communication equipment for Entrants* Required

N/A
Required
Present

If communication equipment is required for Entrants, specify. * Required

Communication cable for confined space entry monitors (can serve as Entrant/Attendant communication method)* Required

N/A
Required
Present

Respirators equipped with appropriate filters and/or cartridges* Required

N/A
Required
Present

If respirators are required, specify type.* Required

Ladder or other approved means for gaining safe entry (if fixed ladder or stairs are not present)* Required

N/A
Required
Present

Protective clothing* Required

N/A
Required
Present

If protective clothing is required, specify.* Required

Hard hat/bump cap* Required

N/A
Required
Present

Gloves* Required

N/A
Required
Present

If gloves are required, specify.* Required

Eye/face protection* Required

N/A
Required
Present

If eye/face protection is required, please specify.* Required

Appropriate footwear* Required

N/A
Required
Present

If appropriate footwear is required, please specify.* Required

Hearing protection* Required

N/A
Required
Present

First aid kid readily accessible* Required

N/A
Required
Present

Fire extinguisher* Required

N/A
Required
Present

Drinking water readily accessible* Required

N/A
Required
Present

Ground-fault interrupter protection* Required

N/A
Required
Present

Other (specify)* Required

Authorization to Proceed

The Entry Supervisor certifies that all required precautions identified on this permit have been taken and authorize work to proceed as described. Attendants and Entrants have been instructed to evacuate the space and to notify the Entry Supervisor immediately if any of these precautions cannot be maintained. The confined space entry points on the map have been marked/circled to aid in first responder notification and response.* Required

Checking this box will serve as acknowledgment and signature.

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files

Requester Info

Permit Date & Time

Location

Entry Details

Authorized Personnel More information

Hazards in Confined Space More information

Mandatory Preparations More information

Preparations More information

Mandatory Equipment More information

Equipment Required for Safe Entry More information

Authorization to Proceed

Add Supporting Documents

Authorized Personnel

Hazards in Confined Space

Mandatory Preparations

Preparations

Mandatory Equipment

Equipment Required for Safe Entry