University of New Hampshire
Confined Space Entry Permit
Date: Start Time: End Time*:

Space ID: EMH0007 Space Name: Electrical Manhole EMH0007
Space Description: Electrical manhole located int the lawn near the South East side of the Dimond Library. May be labeled 34K-11B-5b. Location/Floor: N/A
Reason for Entry: Room: N/A
Trained Entry Team
Entry Attendant: Authorized Entrant:
Entry Supervisor: Authorized Entrant:
Rescue Team: Notification (method, date, time):
SECTION A: GENERAL INFORMATION
Section A and Section B comprise the Pre-Entry Plan and must be submitted to Rescue Services and OEHS Prior to entry
*Permit valid for duration of work not to exceed a single shift or not greater than eight hours. Permit to remain at space for the duration of the entry.
SECTION B: PRE-ENTRY PLAN
REQUIREMENTS TO BE COMPLETED PRIOR TO ENTRY (Choose either yes, no, or N/A for items that do not apply)
Area security and barricades Personal Protective Equipment
Control of Hazardous Energy (LOTO)Protective coveralls:
Mechanical Protective gloves:
Electrical Respiratory Protection:
Pneumatic APR
Hydraulic SAR
Chemical
Thermal
Lines broken, capped, or blanked Head Protection (hard hat)
Space purged, flushed, and/or vented Hot Work (welding, cutting, burning)
Lighting (Intrinsically safe) Ladder
Retrieval Equipment Fire Extinguisher
Describe all equipment and procedures required for entry:
Describe method of communication to be utilized during entry:
Air Monitoring Equipment Atmospheric Hazards/Sensors (list all):
Manufacturer:
Specify:
Date of last annual calibration:
Model:

Specify:
Date and time of bump test:
Air Monitoring Equipment Atmospheric Hazards/Sensors (list all):
Manufacturer:
Specify:
Date of last annual calibration:
Model:
Specify:
Date and time of bump test:

University of New Hampshire
Confined Space Entry Permit Instructions

SECTION A: GENERAL INFORMATION

  • Date: Fill in the date of the entry.
  • Start Time: Fill in the proposed start time of the entry.
  • End Time: Fill in the proposed end time of the entry. Confined space entry permits are valid for a single shift or no greater than 8 hours.
  • Reason for Entry: Provide a brief description of the work to be conducted during entry operations.
  • Trained Entry Team: Clearly print the names of the Entry Supervisor, Attendant, and all Entrants. At a minimum there must be an Entrant and a Supervisor/Attendant.
  • Rescue Team: Fill in the name of the Confined Space Rescue Team. The rescue team must be notified in advance of the entry and may require a pre-evaluation prior to entry.
  • Notification: Indicate the pre-entry notification to the rescue team by method (e.g., phone call, fax, meeting), and the date and time of pre-entry notification. NOTE- if the rescue team is the Durham Fire Department, notifications must be made by fax of the permit, or personal meeting.
SECTION B: PRE-ENTRY PLAN
  • Area security and barricades: Check "yes" if traffic controls or site security will be used. Some form of traffic controls or site security is required for all entry. Traffic controls and site security may include guard rails, traffic cones, and/or cordoning.
  • Control of Hazardous Energy (LOTO): Check "yes" if the entry will require the control of hazardous energy and check applicable energy source(s). Check "no" if the entry will proceed without locking out or tagging out sources of hazardous energy (explain fully below). Mark N/A if there are no sources of hazardous energy in the space.
  • Lines Broken, Capped, or Blanked: Check "yes" if the entry will require capping or blanking of lines carrying fluids. Check no if the entry will not require capping or blanking of lines carrying fluids. Check "N/A" if no lines carrying fluids are present.
  • Space purged, flushed, and/or vented: Check "yes" if the entry will require forced air ventilation to purge and maintain a safe atmosphere. Check "N/A" if there is no real or potential hazardous atmosphere and ventilation will not be used. (Describe ventilation below).
  • Lighting (Intrinsically safe): Check "yes" if lighting is necessary, Check "no" if not. Check "intrinsically safe" if lighting is required for use in a potential combustible/flammable atmosphere.
  • Retrieval Equipment: Check "yes" if non-entry rescue retrieval equipment will be used. Check "no" if non-entry retrieval equipment will not be used. If checked No, explain in detail. Fall arresting equipment is required for all vertical entries greater than 4 feet in depth.
  • Personal Protective Equipment: Check "yes" if personal protective equipment will be used. Check appropriate box for applicable PPE and list PPE selected. Some form of personal protective equipment is required for all confined space entries.
  • Respiratory Protection: Check "yes" if entrants will wear respiratory protection. Check "no" if entrants will not use respiratory protection. Check "N/A" if there are no real or potential atmospheric hazards. Check applicable respirator type and indicate specific respirator to be used (i.e,. ½ face APR, full face APR, air line system, SCBA). For APR, list filter cartridge to be used.
  • Head Protection: Check "yes" if overhead hazards require the need for head protection.
  • Hot Work: Check "yes" if hot work will be performed during the entry. Hot work includes welding, cutting, brazing, and soldering. "yes"efer to the UNH Hot Work Program and permit system.
  • Ladder: Check "yes" if ladder is necessary for entry.
  • Fire Extinguisher: Check "yes" if entry operations require presence of fire extinguisher. (If hot work is check"yes"xtinguisher is required).
  • Describe all equipment and procedures required for entry: Use this space to describe the requirements for confined space entry from the above list and additional requirements as deemed necessary by the Supervisor.
  • Describe method of communication to be utilized during entry: Use this space to describe the method of communication to be used between Attendant and Supervisor.