FORM E - Page 1 of 3
Energized Electrical Work Permit
Job /Work Order Number:_______________________________
Date: ________________________
PART I: TO BE COMPLETED BY THE REQUESTER
11) Description of circuit /equipment /job location:
2) Description of work to be done:
3) Justification of why the circuit/equipment cannot be de-energized or the work deferred until the next scheduled outage:
Requester / Title
Date
PART II: TO BE COMPLETED BY THE ELECTRICALLY QUALIFIED PERSONS DOING THE WORK:
Check when
Complete
1) Detailed job description procedure to be used in performing the above detailed work:
2) Description of the Safe Work Practices to be employed:
3) Results of the Shock Hazard Analysis:
4) Determination of Shock Protection Boundaries:
5) Results of the Flash Hazard Analysis:
6) Determination of the Flash Protection Boundaries:
7) Necessary personal protective equipment to perform the task:
8) Means employed to restrict access of unqualified persons from the work area:
9) Evidence of completion of a Job Briefing including discussion of any job-related hazards:
10) Do you agree the above described work can be done safely?
Electrically Qualified Person
Date
YES
NO
(If no, return to requester)
Electrically Qualified Person
Date
PART III: FACILITY APPROVAL(S) TO PERFORM THE WORK WHILE ELECTRICALLY ENERGIZED:
Maintenance / Engineering Manager
Date
Safety / General Manager
Date
Electrically Knowledgeable Person
Date
Supervisor
Date
3-2011
Energized Electrical Work Permit
FORM E - Page 2 of 3
Energized Electrical Work Permit
Additional Comments
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3-2011
Energized Electrical Work Permit
Energized Electrical Work Permit
FORM E - Page 3 of 3
Energized Work Checklist
To be reviewed by Foreman prior to start of work. Only valid for named wiremen and day issued.
Date: _____/______/______
Start time: ______:______am/pm
Project: ______________________________________________________________________________
Building Location: ______________________________________________________________________
Panel Location: ________________________________________________________________________
Description of Work to be Performed: ______________________________________________________
Specific Reason Equipment Circuit Cannot be De-energized: ____________________________________
_____________________________________________________________________________________
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Maximum Voltage Present: ______________________________________________________________
Number of Voltage Sources Present: ______________________________________________________
Personal Protective Equipment (PPE) worn/used:
Hard Hat
Safety Glasses
Face Shield/ Hood
Flash Resistant Jacket
Flash Resistant Bibs
Insulated Gloves
Insulated Mats
Insulated Blankets
Insulated Sleeves
Hearing protection
Additional PPE Required: ________________________________________________________________
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Work Authorized by: __________________________
Title: ____________________________
Wireman Signature: _____________________________________________________________
Required Signature Second Wireman Assisting: _______________________________________
***On all energized circuits or equipment carrying four hundred forty (440) volts or over, as a safety
measure, two (2) or more journeymen must work together.***
Owner / Customer Representative: _________________________________________________
Time Work Completed: ______:______am/pm
3-2011
Energized Electrical Work Permit
