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 / Date
EHS / 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