ABS Systems, Inc. Energized Electrical Work Permit

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Part 1. To be completed by Requester

• Job Number:

• Description of equipment and/or circuit to be serviced:

• Description of work to be done:

• Description of hazards:

• Justification why equipment/circuit cannot be de-energized:

  Creates additional hazard

  Infeasible due to design or operations

  Required for testing

• Detailed explanation of justification:

• Work Start Date:

  Date

• Work End Date:

  Date

• Requester Name/Signature:

• Date Signed:

Part 2. To be completed by electrically qualified personnel performing work

• NOTE: May be Requester

• Detailed procedures for completing work described above:

• Description of safe work practices to be used:

• Results of shock hazard analysis:

• Determination of shock protection boundaries:

• Results of flash hazard analysis:

• Determination of flash hazard boundary:

• Necessary personal protective equipment to safely perform work:

• Means employed to restrict access to work area by unqualified persons:

• Evidence of job hazard analysis completed?

  Yes

  No

  N/A

• Do you agree work described above can be completed safely?

  Yes

  No

  N/A

• If no, return to requester

• Qualified Person Name/Signature:

• Date Signed:

• Qualified Person Name/Signature:

• Date Signed:

Part 3. Approval to perform electrically energized work

• If no, return to requester

• Job Site Supervisor/Department Manager Approval:

  Yes

  No

  N/A

• Name/Signature:

• Date Signed:

• Safety Committee Member Approval:

  Yes

  No

  N/A

• NOTE: Safety Committee Member must also be electrically qualified person.

• Name/Signature:

• Date Signed: