NFPA 70E Energized Electrical Work Permit

Permit form for authorized energized electrical work under NFPA 70E, capturing equipment details, work justification, shock and arc flash analysis, PPE, approach boundaries, and required approvals.

Work Request Details

• Work Order Number
  Internal work order or maintenance ticket reference.
• Request Date
  Date the permit request is submitted.
• Work Location
  Specific room, area, plant, or site location where the work will occur.
• Is energized electrical work required?
  Select yes only if the task cannot be performed de-energized.
• Type of Work
  Select all activities that apply.

Equipment and Circuit Information

• Equipment Description
  Describe the equipment or circuit involved, including panel, switchgear, motor control center, or other asset.
• Equipment ID / Asset Tag
  Optional asset identifier if available.
• Nominal Voltage (V)
  Enter the nominal system voltage in volts.
• Equipment Condition
  Select the current operating condition of the equipment.
• Single-line diagram available?
  Indicate whether an up-to-date single-line diagram is available for the equipment.

Justification and De-Energization Review

• Justification for Energized Work
  Explain why the task must be performed energized and why de-energizing is not practical, feasible, or would create additional hazards.
• Was de-energization attempted or evaluated?
  Confirm whether lockout/tagout or other de-energization options were evaluated.
• De-Energization Barriers or Constraints
  Select all reasons that apply if the equipment cannot be de-energized.
• Alternate Risk Controls
  Describe any alternate controls used to reduce risk, such as barriers, remote operation, or restricted access.

Shock and Arc Flash Analysis

• Shock hazard analysis completed?
  Confirm that a shock risk assessment has been completed.
• Arc flash analysis completed?
  Confirm that an arc flash risk assessment has been completed.
• Incident Energy (cal/cm²)
  Enter the calculated incident energy at the working distance, if available.
• Arc Flash Boundary (ft)
  Enter the arc flash boundary distance in feet.
• Limited Approach Boundary (ft)
  Enter the limited approach boundary in feet.
• Restricted Approach Boundary (ft)
  Enter the restricted approach boundary in feet.

PPE and Work Controls

• PPE Category
  Select the arc-rated PPE category or equivalent work method used for this task.
• Arc-Rated Clothing Required
  Check if arc-rated clothing is required for this task.
• Insulated Tools Required
  Check if insulated tools are required.
• Voltage-Rated Gloves Required
  Check if voltage-rated gloves are required.
• Additional PPE or Protective Equipment
  List any additional PPE, face protection, hearing protection, or insulating equipment required.

Personnel, Authorization, and Acknowledgment

• Qualified Worker Name
  Name of the qualified person performing the work.
• Supervisor / Approver Name
  Name of the supervisor or authorized approver.
• Safety review completed?
  Confirm that the electrical safety review has been completed before work starts.
• Worker Signature
  Signature confirming the worker understands the hazards and controls.
• Approver Signature
  Signature confirming authorization to proceed with energized work.
• Consent to collect and store submission details
  By submitting this permit, you consent to the collection and storage of the information provided for safety, compliance, and audit trail purposes. Do not include unnecessary PII.