Title Page
-
Outage Location Description (Map location/OCR Number/Outage Number)
-
Date
-
Prepared by
-
Location of Work
Outage Type and Summary
-
Outage Type
-
Description of Work
-
Is wire down?
-
PPE Required
- Rubber Gloves
- Rubber Sleeves
- Head/Eye/Face/Foot Protection
- Arc Rated Clothing
- Reflective Traffic Vest
- Fall Protection
- Other
-
Daily Inspection of Gloves/Sleeves Completed
-
Descrption
-
Select Traffic Control Needed
- Lights
- Cones
- Signs
- Vests
- Flaggers
-
Select Truck Setup Equipment Needed
- Wheel Chocks
- Outrigger Pads
-
Will a preflight test be conducted
Special Precautions
-
Truck(s) Grounded
-
Inspect Pole(s) and Structure(s)
-
Inspect Adjacent Structures
-
All Differences of Potential Will be Covered
Energy Source Controls
-
Is the line de-energized?
-
Is there a visual open
-
Tested and Grounded
-
Is the line still energized?
-
Upstream overcurrent device set to non-reclosing?
-
Device number
-
Describe alternative procedure
Additional Information
-
Additional Information/Questions
Designated Observer
-
Andy Augspurg
-
Andy Barnett
-
Andy Hudson
-
Ben Martin
-
Blake Rodgers
-
Cole Kizer
-
Jacob Kumm
-
Jamie Mannigel
-
Jimmy Sutter
-
John Coleman
-
Kyle Schneider
-
Ross Hein
-
Tanner Gordon
Crew Members and Signatures
-
Andy Augspurg
-
Signature
-
Andy Barnett
-
Signature
-
Andy Hudson
-
Signature
-
Ben Martin
-
Signature
-
Blake Rodgers
-
Signature
-
Cole Kizer
-
Signature
-
Jacob Kumm
-
Signature
-
Jamie Mannigel
-
Signature
-
Jimmy Sutter
-
Signature
-
John Coleman
-
Signature
-
Kyle Schneider
-
Signature
-
Rob Bush
-
Signature
-
Ross Hein
-
Signature
-
Tanner Gordon
-
Signature
-
Wade Begley
-
Signature
-
Other
-
Name
-
Signature