Energized Electrical Work Permit

Permit form for documenting justification, hazard analysis, safe work practices, and approvals for work on energized circuits under OSHA 29 CFR 1910.333 and NFPA 70E.

Permit Details

• Permit Title
• Work Order / Job Number
• Site / Area / Building
• Permit Date
• Requested Start Date and Time
• Requested End Date and Time

Equipment and Circuit Information

• Equipment Name / Tag
• Equipment ID / Asset Number
• Nominal Voltage
  Enter the nominal system voltage, such as 480 V AC or 13.8 kV.
• Energized Parts to be Worked On or Near
• Current Equipment Condition

Energized Work Justification

• Is energized work required?
• Why can the equipment not be de-energized?
• Work Scope Summary
• De-energized Alternatives Considered

Shock and Arc Flash Hazard Analysis

• Shock hazard present?
• Arc flash hazard present?
• Shock Risk Controls
• Arc Flash Risk Controls
• Incident Energy or PPE Category
  Enter the incident energy value or PPE category from the site study or equipment label, if applicable.

Safe Work Practices and PPE

• Pre-job briefing completed?
• Safe Work Practices to Be Followed
• PPE Required
• PPE inspected and in serviceable condition?

Personnel and Approvals

• Requestor Name
• Requestor Role / Title
• Qualified personnel assigned?
• Approver Name
• Approver Title
• Approval Status

Acknowledgment

• Acknowledgment
• Submitter Signature
• Signature Date