Title Page

  • Conducted on

  • Prepared by

  • Location



  • What works will be undertaken?

  • Special Tools / Equipment to be Used

  • Job Location / Plant Identification Number

  • Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

This Permit is only Valid when all sections are complete. If you are in doubt or don't understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE RELEVANT MEMBER OF STAFF.


PRIMARY HAZARDS - Electric Shock / Arcing / Arc Flash / Fire / Explosion

Please answer the questions truthfully

  • Are you Qualified / Trained to undertake this work?

  • Have the relevant departments been advised of the electrical isolation?

  • Has the Electricity Supply been turned off?

  • Has the Fire Sprinkler System been left in service?

  • Have Flammable / Combustible substances been removed from the area?

  • Are Fire Extinguishers required?

  • Is a Fire Blanket Required?

  • Is the site Fire Procedure understood?

  • Is a Voltage Detection Instrument required?

  • Does the Voltage Detection Equipment meet the requirements of HSE Guidance Note GS38 (4th Edition)

  • Is Earthing Required?

  • Are Circuit Breakers required?

  • Are Caution / Danger Signs required?

  • Is Electrical Safety Matting required? Must meet BS EN 61111:2009 Safety Standard.

  • Are Electrical Insulating Gloves required? Must Meet EN60903 Class 0 (1000V) Safety Standard.

  • Have the Electrical Insulating Gloves been Air Tested prior to use?

  • Are 1000V VDE Insulated Tools in Use? Must meet DIN EN 60900:2004

  • Are IP2X Test Ports been used for Live Testing?

  • Is Insulated Shielding required?

  • Has Lock Out Tag Out been undertaken?

  • Has a Test for Dead been conducted?

  • Have stored energy sources been considered? Capacitors / Uninterruptible Power Supplies (UPS) / Solar Voltaic Feed In Systems

  • Is Arc Flash PPE Required? Boots / Overalls/ Gloves / Safety Glasses / Safety Visor must meet IEC 61482-2:2009 Safety Standard.

  • Is a Standby Person present - during Live Electrical Test Work?

  • Is an AED Available - with a trained 1st Aider Present?

  • Is a 1kV Rescue Hook required?

  • Are you likely to come into contact with asbestos? If Yes, an Asbestos Permit to Work will be required.


  • Other Precautions Required to undertake the work safely:

  • Other Safety Equipment required to undertake the work safely:

AUTHORISATION & ACCEPTANCE - I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the works as defined above and the permit has been explained to all workers involved. I accept responsibility for this work.

  • Person in Charge of Works

  • Company

  • Signature

  • Authorising Person


  • Permit Expires on


  • Name of Standby Rescuer (Live Test Works)

  • Emergency Contact Number

  • Rescue Method to be deployed: Rescue Hook / AED etc.

Live Electrical Testing Works are not permitted without a Standby Person trained in effecting a safe electrical rescue.


I confirm that the work has been completed, checked by myself, electrical installation left in a safe condition and the area left in a safe and tidy condition.

  • Person in Charge (Print Name)

  • Person in Charge (Signature)

I have inspected the completed work, confirmed electrical equipment is left in a safe condition and returned any isolated fire protective equipment (Alarms / Sprinklers) to its normal status. I hereby cancel this permit.

  • Authorised Person (Print Name)

  • Authorised Person (Signature)


  • Permit Cancelled

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.