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

Campus, Building, or Outdoor Area* Required

Additional Location Details

Basic Information

Name of Confined Space* Required

Location of Work* Required

Description of Work* Required

Reason for Entry* Required

Employees Assigned* Required

Outside Contractor(s)* Required

Permit Valid From

Entry Date* Required

Entry Time* Required

Permit Expires* Required

Barricades/Signs in Place

Barricades/Signs in Place* Required

Isolation/Energy Checklist

Isolation/Energy Checklist * Required

Isolation/Energy Checklist (check all that apply)* Required

Blanking (hazardous materials)
Bleeding (any pressurized lines)
Blocking (any potential energy)
Mechanical (lockout)
Chemical (cleaned)
Electrical Lockout
Thermal (room temp)
Other

If "Other" selected, please specify* Required

Hazardous Work

Hazardous Work* Required

Hazardous work (check all that apply)* Required

Flame cutting
Open flame (brazing, soldering)
Welding
Cleaning
Painting/Coating
Other

If "Other" selected, please specify* Required

Hazards Expected

Hazards Expected* Required

If "Other" selected, specify* Required

Confined Space Cleaned

Confined Space Cleaned* Required

Inspectied after cleaning* Required

Fire Safety Precautions

Fire Safety Precautions* Required

Personal Safety

Atmospheric Monitoring

Atmospheric Monitoring* Required

Type of Test Performed* Required

Oxygen
LEL
H2S (Hydrogen Sulphide)
CO2 (Carbon Dioxide)
CO (Carbon Monoxide)
Toxic Gases (Specify)
Other

Location of Test* Required

Reading of Test* Required

Continuous Monitoring Required

Continuous Monitoring Required* Required

Remarks* Required

Tests Performed By* Required

Instruments Used* Required

Serials Numbers* Required

Calibration Dates* Required

Calibrated By* Required

Authorizations

Supervisor* Required

Workers Involved* Required

Entry and Emergency Procedures Understood

I, as Safety Watch Person, understand my role.* Required

I, as worker, understand the procedures.* Required

I, as Rescue, understand the procedures.* Required

Add Supporting Documents

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

Files