EHS Energized Electrical Work Permit

Part I

To be completed by person requesting work.

Building Name:

Date:

Qualified Person:

First NameLast Name

Identification #:

Work to be performed:

Justification of why circuit/equipment cannot be de-energized:

Part II

To be completed by lead qualified person performing work.

Qualified Persons Involved (list QP in Charge first):

Purpose of Task:

Number of Employees Involved:

Approach Limits:

Qualified Person Minimum Working Distances
Flash Protection Boundaries

Arc Flash Boundary:

Limited Approach Boundary:

Restricted Approach Boundary:

Other safe practices which will be used (i.e., location of emergency shut-off)::

Required PPE:

Insulating materials/tools to be used:

Voltage Rated Tools:

Electrical Diagrams:

Risk Assessment Form completed:

Job Briefing completed on Risk Assessment Form:

Control Circuits only (120V or less):

Part III

Approvals to perform work while energized.

Lead Qualified Person:

Additional Qualified Person:

EHS Supervisor or Maintenance Manager/Supervisor:

Certification and Acknowledgment

By pressing submit, I certify that all of the information provided above is true, correct and complete, and all additional supervisors and managers have been notified.

Please verify that you are human:

Sender Name: