Part 1

Part 1 to be completed by Requester

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:

Requester Signature

  • Add signature

Part 2

Part 2 to be completed by the qualified persons doing the work

Detailed job procedure to be used in performing the previously detailed work:

Description of the Safe Work Practices to be employed:

Results of the Shock Hazard Analysis:

Determination of Shock Protection Boundaries:

Results of the Flash Hazard Analysis:

Determination of the Flash Protection Boundary:

Necessary PPE to safely perform the assigned task:

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

Evidence of completion of a Job Briefing including discussion if any job related hazards:

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

Qualified persons doing the work signatures

    Electrically Qualified Person
  • Electrically Qualified Person

  • Date

Job Briefing

Job Breifing

  • The job briefing is to be reviewed by the Foreman/General Foreman with all employees involved before each job requiring energized electrical. All employees are to sign the briefing form before start of work.


  • The hazards

  • The voltage levels involved

  • Skills required

  • Any "foreign" (secondary) voltage source

  • Any unusual work conditions

  • Number of people needed to do the job

  • The shock protection boundaries

  • The available incident energy

  • Potential for arc flash (Conduct an arc flash-hazard analysis)

  • Arc flash protection boundary

  • Has energized electrical permit been completed and signed?


  • Can the equipment be de-energized?

  • Are backfeeds of the circuits to be worked on possible?

  • Is a "standby person" required?


  • Job Plans

  • Single-line diagrams and vendor prints

  • Safety procedures

  • Individuals are familiar with facility

Job Briefing Cont'd

Job Briefing Continued


  • What the job is

  • Who else needs to know --- Communicate!

  • Who is in charge


  • About the unexpected event....What if?

  • Lock - Tag - Test - Try

  • Test for voltage FIRST

  • Use the right tools and equipment, including PPE

  • Install and remove grounds

  • Install barriers and barricades

  • What else...?

Prepare for an emergency

  • Is the standby person CPR trained?

  • Is the required emergency equipment available?

  • Where is it?

  • Where is the nearest telephone?

  • Where is the fire alarm?

  • Is confined space rescue available?

  • What is the exact work location?

  • How is the equipment shut off in an emergency?

  • Are the emergency telephone numbers known?

  • Where is the fire extinguisher?

  • Are radio communications available?


  • Foreman/General Foreman

  • Select date

  • Employee Signature
  • Add signature

  • Select date

Part 3

Part 3 Approval to perform the work while electrically energized

  • May only be signed by:
    General Superintendent-Division Manager-Vice President-President

  • Signature

  • Title

  • Select date

Example 1

Example #1 Installing Breakers

  • Example #1

    Example #1

Example #2

  • Example #2

    Example #2
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