Permit Request • CampusOptics

Please complete the information below to obtain your Work Alone Permit.

Contact EHS for assistance with any of the questions

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Name* Required

Additional Location Details

Enter full name* Required

Contact details (Department, College): * Required

Phone number* Required

Supervisor:* Required

Name and Contact Info. for Person checking on employee:* Required

Method to be used for checking on employee:* Required

Intervals the employee will be contacted:* Required

Location of Activity:* Required

Has a risk assessment (must be attached) been conducted for this task?* Required

Is the employee trained in working alone procedures?* Required

Is the employee aware of all risks associated with the task?* Required

Has a safety inspection been completed prior to operating any equipment?* Required

Have emergency plans been discussed?* Required

Is Personal Protective Equipment (PPE) and training on proper use available? * Required

Have Standard Operating Procedures (SOPs) been provided and discussed?* Required

Have additional controls been put in place during this task/activity?* Required

Communication Arrangements:* Required

Action to be taken if contact is not made in accordance with above schedule:* Required

Signature of Graduate Student/Staff:* Required

Signature of PI or Supervisor:* Required

Duration of Approval: From _________ to __________* Required

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

Files