Confined Space Entry Permit

 BYU-Idaho Confined Space Work Permit

The completed permit must be posted at the work site.

Permit submitted by
Email Address:
Date work to be done

Permit good for 24 hours only!

Time work to be started
Time work completed
Work Order Number
Location of work
Nature of work
Other Hazardous Work
Entrant/s
Attendant/s
Department or Shop
Oxygen Reading
LEL Flammability Reading
Hydrogen Sulfide Reading
Carbon Monoxide Reading
Chlorine Reading
Required Check List
Yes No 1. Was a pre-entry hazard assessment conducted?
Yes No 2. Is Lockout/Tagout required?
Yes No 3. Is mechanical ventilation required?
Yes No 4. Is Respiratory protection required?
Yes No 5. Do you have communications on site?
Yes No 6. Are barriers erected at vault entrance?
Yes No 7. Is adequate personal protective equipment being used?
Yes No 8. Will a copy of the permit be posted at the work site?
Yes No

9. Will vault be secured after completion of work?

Print a copy of this permit using your tool bar print function and keep the copy at the work site.                                              

Then click on the "Submit Request" button below after printing a copy of the permit.

Upon completion, e-mail the safety office noting of completion and any problems that may have been encountered.   

IN CASE OF AN EMERGENCY CALL 911 .   DO NOT ENTER THE CONFINED SPACE.   WAIT FOR RESCUE PERSONNEL.

           (Save a copy for your records)