Confined Space Permit Entry Request Form

Confined Space Permit Entry Request Form

Use this form to request a permit for a confined space entry. Form must be complete at least 24 hours in advance of the planned entry. The safety team will have the permit and a meter ready for you on the date of entry.

This process is only for PLANNED confined space entries. IF YOU HAVE AN EMERGENCY ENTRY, PLEASE CALL THE SAFETY TEAM DIRECTLY TO COORDINATE:

Justin Zunker: 541-346-0780

Haily Griffith: 541-520-3677

REMINDER: each vault requires its own permit so please fill out a separate form for each space you are entering, even if the spaces are located near each other.

Your Name

Your Department

Date of Entry

Start time

Estimated end time

REMINDER: permits are only valid for up to 12 hours. Any work that will exceed this time will require a second permit.

For outdoor spaces, please list closest university building

Please state a brief description of the work to be performed.

For example: backflow preventer valve, investigate pump, pull fiber, etc.

Name of Entrants(s)

Please list all of the employees who may break the plane of the confined space.

REMINDER: all entrants must have valid First Aid/CPR training to enter a permit required confined space.

Name of Attendant(s)

REMINDER: all attendants must have valid First Aid/CPR training to attend a permit required confined space.

Do you need any additional support from the safety team?

Select

Support

List the type of support you need (i.e. requesting a pre-job site visit, review of safety plan, or other safety concern associated with this job). Please include a means to contact you to coordinate support.

Upload supplementary documents here (optional)

Drag and drop files here or

Your Email

Send me a copy of my responses

Privacy Notice|Report Abuse