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Energized Electrical Work Permit and Assessment



 
Justification for Energized work request:
 Shut down creates an increased/additional Hazard (specify)
 Shut down is infeasible due to design or operational hazards (specify)
 
 
Requested by:
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Title:
Date:
 

Hazard Analysis (To be completed by the electrically qualified persons doing the work)

 
 120 Volts
 240 Volts
 208 Volts
 277 Volts
 Emergency power
 480 Volts
 DC
 <50
 Other
 
Flash Protection Boundary(check method used):
 4'0" (Systems less than 600 volts, with 0.1 second clearing time)
 Other(state source or attach work being performed for boundary)
 
 
 

Shock Analysis/Approach Boundaries:


  ft in
  ft in
 

No jewelry or metal objects can be worn or carried in pockets while completing work requiring an energized work permit. This includes wedding rings, watches, necklaces, keys, etc.

 
Hazard/Risk Category for the task:
 1
 2
 3
 4
 
ATPV(cal) rating for FR clothing:
 
 4 cal
 8 cal
 25 cal
 40 cal
 
Has a documented Pre-task Safety Plan and job briefing been completed?
 Yes, see attached sheet
 No
 
Means employed to restrict access of unqualified persons from work area
 Attendants
 Signs
 Barricades
 
Other protective equipment required
 Insulated Tools
 Portable Ladders
 Rubber Insulating Equip
 Rubber Insulating Equip
 Others
 
 Yes
 No
 
Means of Emergency Communication:
 Cell Phone
 Radio
 Phone
 

Electrically Qualified Person

Do you agree that the work requested can be done safely?
 Yes
 No
 
 
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Safety Director Approval

This Energized Electrical Permit has been reviewed and energized work can proceed:
 
 
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