Electrical - Permit to Work

• Conducted on

  Date

• Prepared by

• Location
  Address

• ELECTRICAL PERMIT TO WORK NUMBER

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Has the Electricity Supply been turned off?

  Yes

  No

  N/A

• Has the Fire Sprinkler System been left in service?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are Fire Extinguishers required?

  Yes

  No

  N/A

• Is a Fire Blanket Required?

  Yes

  No

  N/A

• Is the site Fire Procedure understood?

  Yes

  No

  N/A

• Is a Voltage Detection Instrument required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is Earthing Required?

  Yes

  No

  N/A

• Are Circuit Breakers required?

  Yes

  No

  N/A

• Are Caution / Danger Signs required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are IP2X Test Ports been used for Live Testing?

  Yes

  No

  N/A

• Is Insulated Shielding required?

  Yes

  No

  N/A

• Has Lock Out Tag Out been undertaken?

  Yes

  No

  N/A

• Has a Test for Dead been conducted?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is a 1kV Rescue Hook required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

OTHER PRECAUTIONS

• Other Precautions Required to undertake the work safely:

• Other Safety Equipment required to undertake the work safely:

• Person in Charge of Works

• Company

• Signature

  Sign

• Authorising Person

PERMIT EXPIRY DETAILS

• Permit Expires on

  Date

• 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)

  Sign

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)

  Sign

PERMIT CANCELLED

• Permit Cancelled

  Date