Energized Electrical Work Permit
PART I: JOB SCOPE (to be completed by the requester):
Work Order Number ______
1) Description of circuit/equipment/job location:
2) Description of work to be done:
3) Why can the circuit/equipment not be de-energized or the work deferred until the next scheduled outage?:
Requester’s Name & Title ______Date: ______
PART II: HAZARD ANALYSIS (to be completed by the electrically qualified persons doing the work):
Check when
Completed
1) Detailed job description procedure to be used in performing the above described work: £
2) Description of the Safe Work Practices to be employed: £
3) Is a Standby person required? £ Yes £ No
4) Results of the Shock Hazard Analysis:______£
Limited Approach Boundary______Restricted Approach Boundary______
Prohibited Approach Boundary______
5) Necessary personal and other shock protective equipment to safely perform the assigned task: £
6) Results of Arc Flash Hazard Analysis: £
Incident Energy ______Hazard/Risk Category______
Arc Flash Boundary ______
7) Necessary arc flash personal and other protective equipment to safely perform the assigned task: £
8) Means employed to restrict the access of unqualified persons from the work area: £
9) Evidence of completion of a Job Briefing including discussion of any job-specific hazards: £
10) Do you agree the above described work can be done safely? £ Yes £ No If no, return to requester.
Electrically Qualified Person Date
PART III: APPROVAL(s)* (to perform the work while electrically energized):
Note: Exposed electrical conductors or circuit parts, operating at 50 volts and higher, shall be de-energized before performing work on or near, unless it can be shown that de-energizing creates additional hazards, or is not feasible due to design or operational limitations. Exception: Work by a qualified employee that involves testing, measurement and troubleshooting activities.
Manager’s Name / Manager’s Signature / DateEHS / EHS Signature / Date
Electrically Knowledge Person / Electrically Knowledge Person’s Signature / Date
Note: Once the work is complete, forward a copy of this form to EHS