Energized Electrical Work

Procedure and Permit

7625 Boone Ave. No.

Brooklyn Park, MN 55428
763-544-4131

SECTION I
JOB NAME:
WORK ORDER #:
Extended Duration: ____________ One Time Use Only: ___________ Date Start: ______________ Expiration Date: ______________
(max. 6 months)
Building:
Description of work to be done:

Room/Area:

Job Supervisor:

Description of Circuit/Equipment:
Justification for why equipment cannot be de-energized: (check one)
Note: preference is always to work de-energized.

Exemption 1: De-energizing introduces additional or increased hazards. Examples include interruption of life support equipment,
deactivation of emergency alarm systems, shutdown of hazardous location ventilation equipment, or removal of illumination for an area.
Explain: ______________________________________________________________________________
Exemption 2: De-energizing is infeasible due to equipment design or operational limitations. Example include testing of electrical circuits
that can only be performed with the circuit energized, and work on circuits that form an integral part of a continuous industrial process in a
chemical plant that would otherwise need to be completely shutdown in order to permit work on one circuit or piece of equipment.
Explain: ____________________________________________________________________________________

SECTION IIAPPROVALS TO PERFORM THE WORK WHILE ELECTRICALLY ENERGIZED

(Add signature and date)
______________________________________ Person Requesting the Work
_________ Date
______________________________________ Qualified Worker

_________ Date

_______________________________________ Authorized Owner/Representative

_________ Date

(Signature of Qualified Worker verifies the worker is trained and informed of all hazards relevant to this work task.)
Two persons required for energized work over 240 volts
SECTION IIIRESULTS OF THE SHOCK RICK ASSESSMENT Protective Boundaries and Glove Class
Shock Hazard Maximum Voltage _____________________________ Glove Voltage Rating ________________________
(Check gloves before use and check certification date inspection date within 6 months)
Indicate which boundaries apply by checking the following boxes: (The dimension associated with each of the boundaries depends on the
maximum voltage to which a worker might be exposed: All dimensions are distance from energized electrical conductor or circuit part to
employee)
Limited Approach Boundary
Restricted Approach Boundary
Closest approach distance for an UNQUALIFIED person.
Nominal System
Voltage Range,
Phase to Phase

Exposed Movable
Conductor

Exposed Fixed
Circuit Part

Check one:

50 300 Volts 10 FT.

3 FT. 6 IN.
301 750 Volts 10 FT.
3 FT. 6 IN.
____________ ____
__________
Label ______________________________________

Closest approach distance for a QUALIFIED worker unless voltage rated gloves and tools are used.

Includes Inadvertent Movement Adder

50-150 Volts Avoid Contact

151-750 Volts 1 FT. 0 IN.
_____________________
Label ____________________

NOTE: ALL WORK AREAS WILL BE BARRICADED TO PREVENT UNQUALIFIED PERSONS ENTERING/CROSSING THE
LIMITED APPROACH BOUNDARIES

1/2015 Revised

SECTION IV - RESULTS OF THE FLASH RISK ASSESSMENT (NFPA 70E 2009 130.3) Hazard Rating and Protective Boundaries

Label ______________________________________________________
Arc Flash Boundary: Using table 130.7(C)(15)(A)(b) or 130.7 (C)(15)(B)
Any person working within the Flash Boundary will be required to use the appropriate level of Arc Flash PPE.
To determine the correct level of PPE, refer to:

Label ______________________________________________________
Personal Protective Equipment (PPE) Selector
Or
NFPA70E Table 130.7(C)(15)(A)(b) or 130.7(C)(15)(B)
Or
Level of PPE

0
1
2
3
4
SECTION V

4 Cal
8 Cal
25 Cal
40 Cal

JOB BRIEFING (Description of Safe Work Practices to be employed)

Document job debriefing by reviewing and checking all categories below. Document any discussion relating to any job specific hazards here:
Identify
The hazards
The voltage levels involved
Skills required
Any foreign (secondary source)
Any unusual work conditions
Number of people needed to do the job
The shock protection boundaries
The available incident energy
Ask
Are backfeeds of the circuits to be worked on possible?
Is a standby person required?
Check
Job plans
Single-line diagrams and vendor prints
Status board
Information on plant and vendor resources is up to date
Safety procedures
Vendor information
Individuals are familiar with the facility

Know
What the job is
Who else needs to know Communicate!
Who is in charge
Think
About the unexpected eventWhat if?
Lock Tag Test -Try
Test for voltage FIRST
Use the right tools and equipment, including PPE Install and
remove grounds
Install barriers and barricades
What Else..?
Prepare for an Emergency
Is the standby person CPR trained?
Is the required emergency equipment available? Where is it?
Where is the nearest telephone?
Where is the fire alarm?
Is confined rescue available?
What is the exact work location?
How is the equipment shut off in an emergency?
Are the emergency telephone numbers known?
Where is the fire extinguisher?
Are radio communications available?

Briefed Qualified Worker _________________________________________Date ______________________________________

Briefed Qualified Worker _________________________________________Date ______________________________________
RETURN COMPLETED AND APPROVED WORK PERMITS TO THE EGAN PROJECT MANAGER
2015 NFPA70E Standard is available on Chromebooks/Reference materials NFPA70E Handbook for Electrical Safety in the Workplace

1/2015 Revised