University of Rochester

Guest

University of Rochester

Confined Space Entry (IN PROCESS/TESTING) Permit Request

UNIVERSITY OF ROCHESTER

ENVIRONMENTAL HEALTH & SAFETY

This permit is valid for the day of issue only. All checks and atmospheric tests are to be completed on day of entry, prior to entry. Atmospheric testing is required for any changes in the confined space or surrounding work environment (record interval checks on page 2 of permit). Post this permit on job site. Retain a department copy. Send one copy to EH&S upon completion. All entry team personnel have the right to observe atmospheric testing to their satisfaction

1. Ensure proper Lock Out / Tag Out; verify de-energization and dissipated energy

2. The outside observer must constantly be stationed outside the confined space near the entrance and maintain constant contact, visual and/or verbal, with those inside the confined space.

3. All entry team personnel must be informed of the nearest telephone, fire alarm, emergency shower and eyewash.

4. Do not enter the confined space unless all items on the front of this permit are satisfied.

5. All entry personnel must have received confined space training prior to entry. The signatures on the front of the permit signify this.

6. Record additional atmospheric testing below. Use another sheet if necessary.

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

Basic Information

Emergency Telephone Numbers * Required

Job Site * Required

Job Working Supervisor* Required

Supervisor Telephone* Required

Confined Space Description* Required

Confined Space Contents* Required

Confined Space Last Contained* Required

Description of Work* Required

Date of Entry* Required

Entry Team Leader (ETL)* Required

ATMOSPHERE TEST INSTRUMENTS

1. Manufacturer

1. Model* Required

1. Serial No.

1. Calib Date

1. Calib Due

2. Manufacturer

2. Model

2. Serial No.

2. Calib Date

2. Calib Due

Atmosphere Test Requirements

Oxygen in Space (O2): Field Checker Signature

Oxygen in Space (O2): Meter Reading %

Oxygen in Space (O2): Time

Oxygen in Space (O2): Is Continuous Test Required?

Oxygen in Space (O2): Permissible Exposure Limit > 19.5 % - < 23 %

Hydrogen Sulfide (H2S): Field Checker Signature

Hydrogen Sulfide (H2S): Meter Reading ppm

Hydrogen Sulfide (H2S): Time

Hydrogen Sulfide (H2S): Is Continuous Test Required?

Hydrogen Sulfide (H2S): Permissible Exposure Limit < 10 ppm

Carbon Monoxide CO): Field Checker Signature

Carbon Monoxide CO): Meter Reading ppm

Carbon Monoxide CO): Time

Carbon Monoxide CO): Is Continuous Test Required?

Carbon Monoxide CO): Permissible Exposure Limit < 10 ppm

Flammability (LEL): Field Checker Signature

Flammability (LEL): Meter Reading % LEL* Required

Flammability (LEL): Time

Flammability (LEL): Is Continuous Test Required?

Flammability (LEL): Permissible Exposure Limit < 10 %

Oxygen-Airline Respirator: Field Checker Signature

Oxygen-Airline Respirator: Meter Reading %

Oxygen-Airline Respirator: Time

Oxygen-Airline Respirator: Is Continuous Test Required?

Oxygen-Airline Respirator: Permissible Exposure Limit > 19.5 % - < 21 %

Other Toxic Gas: (Specify)

Other Toxic Gas: Field Checker Signature

Other Toxic Gas: Meter Reading

Other Toxic Gas: Is Continuous Test Required?

Other Toxic Gas: Permissible Exposure Limit

Authorization

Entry Team Leader

Entry Team Attendant

Entrant 1

Entrant 2

Entrant 3

Entrant 4

Entrant 5

Entrant 6

Add Supporting Documents

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

Files

© 2026 CampusOptics, Inc. All rights reserved.