Energized Electrical Work & Inspection Permit

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Part I: Work Information

Part II: Job Description and Safe Work Practices

Complies with AHA 007 High Voltage Electric Work and Work Around Live Cables Yes No

Shock Hazard Analysis

Shock hazard present: exposed energized conductors at ___V during ___. Contact risk exists at (list components). Controls required.

Flash Hazard Analysis

Arc flash hazard present at ___V. Incident energy at working distance is ___ cal/cm² and arc flash boundary is ___ (ft/in). Minimum arc rating required: ___ cal/cm².

Safe Plan of Action followed from Electrical Safety Checklist Yes No

Part III: Lock Out Tag Out

Upload photo evidence of proper PPE donning

Energy Sources Identified? Yes No
PPE: CAT II Arc Flash Suit Donned? Yes No
Notification of affected personnel? Yes No
Equipment/Circuit shut down? Yes No

LOTO Installation

Zero Energy Verification

Equipment in Electrically Safe Condition for inspection to continue? Yes No

Part IV: Completion

Inspection Completed? Yes No
Notification to all affected personnel of reenergization? Yes No
Removal of all energy isolating devices complete and safety devices reinstalled? Yes No
Equipment reenergized and in normal functioning condition? Yes No