Energized Electrical Work Permit

Work Order #:_________________

Completed by the REQUESTER
Location :
Equipment ID & type:
Work to be performed:
Justification why the equipment cannot be de-energized, or done during next outage:

Start Date: Expiry Date:

Requester: Date:

Completed by the ELECTRICALLY QUALIFIED PERSONS doing the work

Safe work practices employed:
 Job safety plan approved  Detailed procedures written  Two Workers

 Job briefing done  Emergency plan reviewed  Safety Watch

Highest voltage exposed to: Incident energy (cal/cm2) OR Arc

Limited approach boundary: Flash PPE Category:
Restricted approach boundary: Arc flash boundary:
Minimum glove class: Minimum Arc Rated PPE:
How will access to work area be
restricted:

Do you agree the above task can be done safely ?  Yes  No

Qualified Electrical Worker: Date:

Qualified Electrical Worker: Date:

Completed by the APPROVERS

Chief Electrical Person: Date:

Maintenance Manager: Date:

Operations Manager: Date:

info@leafelectricalsafety.com +1 800-822-9532
 Energized Electrical Work Permit
Work Order #:_________________
Completed by the REQUESTER
Location :
Equipment ID & type:
Work to be performed:
Justification why the equipment cannot be de-energized, or done during next outage:

Start Date: Expiry Date:

Requester: Date:

Completed by the ELECTRICALLY QUALIFIED PERSONS doing the work

 Job safety plan approved & attached  Job briefing done

Do you agree the above task can be done safely ?  Yes  No

Qualified Electrical Worker —

Date:
Person-in-charge:

Completed by the APPROVERS

Chief Electrical Person: Date:

Maintenance Manager: Date:

Operations Manager: Date:

info@leafelectricalsafety.com
+1 800-822-9532