Energized Electrical Work Permit

for Activities with Hazard/Risk Category 1, 2, or 3

PART 1: To be completed by Requester: Where in the facility will task(s) be performed __________________________________________________ Describe task(s) to be performed:

PART 2: To be completed by Qualified Person: Flash Protection Boundary Distance __ feet, __ inches. (from one-line drawing or equipment label) - Limited Approach Boundary 3 feet, 6 inches - Restricted Approach Boundary Distance 1 feet, 0 inches - Prohibited Approach Boundary 1 inch

Required PPE:

Untreated cotton underwear Safety glasses or goggles Leather shoes

FR long-sleeved shirt & pants, or coveralls Hardhat with arcrated face shield Hearing protection

Voltage rated electrical gloves Leather gloves

Check Means of Restricting Area:

Locked room Warning sign(s) Cones & caution tape or equivalent barrier Attendant

Check Safe Work Practices & Emergency Procedures:

Voltage-rated tools Fire extinguisher Install barrier between energized circuits Nearby telephone, cellphone, or radio

Check volt meter Emergency phone number ________________

Other:_____________________________________________________________________________________________________ _ PART 3: Approval Signatures: Job Safety Briefing has been conducted and work can be performed safely. Qualified Person/Title Approved by: Electrical Safety Coordinator Production Manager Date Date Date

Electrical Safety Program

rev. 10/19/07