Submitter's Name:
*
First Name
Last Name
Department:
*
Phone:
*
Please enter a valid phone number.
Format: 000-000-0000.
Email:
*
example@tmcc.edu
Equipment:
*
Equipment Location:
*
Date Evaluated:
*
-
-
2 digit month, 2 digit day, 4 digit year
Task:
*
Voltage:
*
Risk Assessment
Hazards:
*
Consequences (Severity):
*
Likelihood of Occurrence:
*
Yes
No
Risk Reduction Controls (Hierarchy of Controls):
*
Approach Boundaries (Shock Prevention)
Limited Approach Boundary (50V to 750V):
3.5 Feet
Restricted Approach Boundary (50V to 150V):
Avoid Contact
Restricted Approach Boundary (151V to 750V):
1 Foot
Metal clad Switchgear 1 kV to 15 kV:
N/A
Arc Flash:
PPE Category 4
Boundary 40 Feet
A NO answer indicates that all requirements have not been met:
*
Rows
Yes
No
1. Have hazards been identified?
2. Have the voltage levels been identified?
3. Has any foreign voltage been identified?
4. Have unusual work conditions been reviewed?
5. Have arc flash protection boundaries been identified & implemented?
6. Is an attendant available?
7. Have you determined if PPE is required? If so, ensure that the PPE has been inspected and donned by all persons performing work?
8. Is the location of the nearest fire extinguisher known?
9. Is the location of the telephone known?
10. Has the equipment shut off/disconnect been located?
Please verify that you are human
*
Sender Name:
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