Contents

OTHER EQUIPMENT (Energized Electrical Work Permit: Page 1 of 2)
Isolation and shielding materials: Safety grounding cables Insulated mats Insulated blankets Voltage-rated ground
equipment Other: ____________________________________________________________________________________
Tools: Insulated voltage-rated tools Isolating/operating sticks Fuse handling equipment Other: _________________
Testing equipment:
______________________________________________________________________________________________________
Other equipment: Auxiliary lighting Non-conductive ladders Non-conductive ropes/handlines Safety signs, tags,
barricades Fire extinguisher
Other: _____________________________________________________________________________________________
APPROVALS TO PERFORM THE WORK WHILE ELECTRICALLY ENERGIZED
Signature-Lead Qualified Person: ____________________________________
Signature Qualified Person: ________________________________________
Signature Qualified Person _________________________________________
Signature Responsible HSM ________________________________________
Date: __________
Date: __________
Date: __________
Date: __________
Job Briefing and Planning Checklist:
1. Has hazards been identified? Y N
2. Have the voltages been identified? Y N
3. Has any foreign (secondary source) voltages been identified? Y N
4. Unusual work conditions been reviewed? Y N
5. Have flash protection boundaries been identified and implemented? Y N
6. Is a standby person required and available? Y N
7. Has proper PPE been inspected and donned by all persons performing work? Y N
8. Is the location of the nearest fire extinguisher known? Y N
9. Is the location of the telephone known? Y N
10. Has the equipment shut off in been located? Y N
Completed by (signature)__________________________________ Date: _______________
A-73 GNV310133632156.DOC/090840008