Information

  • Issuance Date and Time

  • Expiration Date and Time

  • Voltage of Work

  • Work Location
  • Document No.

  • Client / Site

  • Prepared by

  • Personnel

ANSWER THE FOLLOWING

  • Have all affected personnel in the area been notified of the energized electrical work?

  • Have all circuits been disconnected that can possibly be disconnected?

  • Will protective gloves and sleeves be used?

  • Have they been inspected?

  • Have all energized lines been insulated or covered with protective covering that can be?

  • Will protective gloves and sleeves be used? <br><br><br><br>

  • Have they been inspected and determined in good condition for the work to be performed?

  • Are ladders that are going to be used of the non conductive type?

  • Have this ladders been inspected?

  • What type of platform will be used to work

  • What type of platform

  • Is there a second person on the job?

  • Is that person CPR/ First aid trained?

  • Is lockout/tagout required and used?

  • Has procedure been followed

  • Why not?

  • Are all flammables removed from the area

  • Why not

  • Has a JSA been completed

The above items had been checked and the area is considered to be safe to proceed with the energized electrical work described above.

  • Job Superintendent

  • Project Manager

  • Health and Safety Manager

Work has been completed and equipment is back to normal. Permit is removed from the field.

  • Job Superintendent

  • Health and Safety Manager

Job Safety Analysis

  • Prepared by

  • Approved by

  • SEQUENCE OF JOB STEPS

  • POTENTIAL HAZARDS

  • Please explain

  • Required PPE

  • Recommended Action or Procedure to eliminate potential hazards

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