Permit Request • CampusOptics

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

Activity and Contact Information

Program / activity name* Required

Department / organization* Required

Designated Individual (Organizer/Mentor)* Required

Faculty sponsor/PI (If different than above)* Required

On-site emergency contact (Name/Phone)* Required

Designated Individual Email* Required

Designated Individual Phone* Required

Proposed start date* Required

Proposed end date* Required

Number of minors expected* Required

Days / hours of participation* Required

Building and room(s)* Required

Purpose of the program or activity* Required

Hands-On Activity Description and Scope

Step-by-step description of hands-on tasks* Required

Materials, chemicals, biological agents, organisms, specimens, tools, or equipment to be handled* Required

Locations where work will occur and areas that will remain prohibited* Required

Other activity category

Will the minor work independently at any time?* Required

Independent-work explanation, if applicable

Hazard Identification and Risk Controls

Other hazard(s)

Risk assessment: potential exposure routes, foreseeable incidents, and severity* Required

Describe engineering controls, administrative controls, work practices, and activity limitations* Required

Personal Protective Equipment and Hygiene

Other PPE and size / availability arrangements

PPE donning, doffing, disposal, cleaning, and replacement instructions* Required

Hygiene controls* Required

No food or drink in the work area
Handwashing required before leaving
Contaminated PPE remains in designated area
Personal items stored outside work area
Other hygiene controls

Other hygiene controls

Proposed Training and Competency

Other required minor training (Attach any other supporting documentation)* Required

Method used to verify understanding and competency* Required

Supervision, Emergency Procedures, and Incident Response

Required supervision ratio* Required

Designated alternate supervisor* Required

Required supervision * Required

Direct line-of-sight supervision required
Supervisor will remain in the same room
Minor will not work after normal hours 8am-5pm
Buddy system required (no 1:1 supervision is allowed)
Access will be limited to approved areas
Other supervision condition

Other supervision condition

Emergency procedures, evacuation route, emergency equipment, and notification process* Required

Spill, exposure, injury, or near-miss response and reporting plan* Required

Emergency equipment reviewed

Emergency exits reviewed
Eyewash / shower location reviewed
Fire extinguisher / alarm location reviewed
First-aid resources reviewed
Emergency contact method tested
Incident reporting expectations reviewed

Prohibited Activities and Restrictions

Prohibited activities and access restrictions* Required

Documentation and Approvals Checklist

Approvals Checklist* Required

Completed hands-on activity authorization form
Detailed procedure / protocol or SOP
Participant roster, if applicable
Parent / guardian consent

Designated Individual (Organizer/Mentor) Certification

Designated Individual (Organizer/mentor) name* Required

Title / role* Required

Individual completing the form* Required

Date* Required

Add Supporting Documents

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

Files