Permit Request • CampusOptics

Requester

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

Requester

Have you completed Fall Protection training within the past 3 years?* Required

Yes
No - Please contact your Supervisor

If there are other workers involved in this activity, please list their names below. * Required

Work Activities

Work activities* Required

Fall Hazard Location(s) where a fall protection plan is needed* Required

Fall Hazards

Leading Edge?* Required

Yes
No

Unguarded Opening?* Required

Yes
No

Uneven working surface* Required

Yes
No

Boom Lift/Scissor Lift* Required

Yes
No

Is the roof slope less than 4:12 (flat roof)?* Required

Yes
No - contact your supervisor

Is there a swing fall hazard?* Required

Yes
No

Fall Protection Systems to Be Used (choose all that apply)

Type of Fall Protection to be used* Required

Fall restraint (e.g. parapet anchor)
Fall arrest
Alternate safe work procedures – control zones and safety monitors
Alternate safe work procedures – other (explain in box further below)

Fall Protection Procedures* Required

Rescue Plan* Required

Self-rescue - use self rescue straps
Assistant rescue - to be assisted by crew or use a aerial lift
Emergency rescue - call 911

Working at Height Hazards

Poor environmental conditions (e.g. temperature, ice, rain, heavy winds)* Required

Yes
No

Overhead hazards (i.e. high voltage power lines)* Required

Yes
No

Wet or oily surfaces* Required

Yes
No

Slippery surfaces with limited or no traction* Required

Yes
No

Spills* Required

Yes
No

Loose floor materials* Required

Yes
No

Inadequate lighting* Required

Yes
No

Uneven walking surfaces, tripping hazards* Required

Yes
No

Pedestrian and traffic control below* Required

Yes
No

Equipment, machinery, materials below* Required

Yes
No

Work carried out at an elevation (i.e. on a ladder or scaffold) relative to an unguarded edge* Required

Yes
No

Supervisor

Trades Supervisors * Required

My Supervisor is not on the list
McKen Cheung
Aidan McDonnell
Bill Thier
Mike Romanisson
Mike Brown
Manraj Ghuman

Names of your Supervisors, if their names are not included in the list above

Add Supporting Documents

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

Files