Clone of Non-Permit Confined Space Entry

Permit Number

Your Company Name

Electrical Worker's Name

First NameLast Name

Electrical Worker's Email

example@example.com

Is the Electrical Worker qualified by the Company to perform Energized Electrical Work?

Welcome to the Energized Electrical Work Permit

This form is used to ensure that all energized electrical work is properly evaluated, controlled, and authorized before it begins. Working on or near energized systems presents serious hazards, including electric shock, arc flash, and arc blast. By completing this permit, you verify that de-energizing has been considered first, that all feasible safety measures are in place, and that only qualified personnel are performing the work under approved conditions..

Purpose and Scope:

The purpose of this permit is to provide written authorization and documentation confirming that energized electrical work cannot be performed in a de-energized state and that all required protective measures have been identified, implemented, and reviewed. This includes verification of qualifications, PPE, safe work boundaries, shock and arc flash protection, and proper supervision. The permit ensures compliance with OSHA 29 CFR 1910 Subpart S and NFPA 70E, supporting a safe and controlled approach to energized electrical tasks.

Stop Work Statement

If any conditions change, protective measures become ineffective, or hazards increase beyond what was originally evaluated, all energized work must stop immediately. The permit must be re-evaluated, and authorization renewed before work can continue. No task or schedule is ever more important than the safety of personnel involved.

Date and Time of Permit Issue

Location of Energized Electrical Work

Under NFPA 70E, there are only two instances in which an employee can work on live parts. Please note if one or both conditions apply to this permit:

Description of circuit/equipment/job location:

Description of work to be done:

Justification of why the circuit/equipment cannot be de-energized or the work deferred until the next scheduled outage:

1. Detailed job description procedure (JHA, JSA, JRA, etc.) to be used in performing the above detailed work:

2. Description of the safe work practices to be employed:

3. Results of the shock hazard analysis:

4. Determination of shock protection boundaries:

5. Results of the flash hazard analysis:

6. Determination of the flash protection boundary:

7. Necessary personal protective equipment to safely perform the assigned task:

8. Means employed to restrict the access of unqualified persons from the work area:

9. Evidence of completion of job briefing including discussion of any job-related hazards:

10. Do you agree the above described work can be done safely?

*STOP*

Based on the above answers you provided, you are not qualified to perform Energized Electrical Work for the Company!!!

Supervisor Approval (Type Full Name)

Note: An edit link will be emailed to the Supervisor, allowing both the Supervisor and the Electrical Worker to edit and modify this form as needed.

If conditions of the work change, stop work immediately and ensure the permit is reviewed and modified to reflect the revised work plan before continuing.

Energized Electrical Work Permit

Details

Justification

Hazard Mitigation

Acceptance