⚡ NFPA 70E Compliant

Energized Electrical Work Permit

SLP Alaska Safety Management System

📋 Permit Information

Permit Initiator *

Date *

Phone/Radio

Client/Company *

Location *

Equipment/Circuit ID *

Nominal Voltage *

Work Description *

Justification for Energized Work *

⚡ Shock Hazard Analysis

Approach boundaries auto-populate from NFPA 70E Table 130.4(D)(a) based on the Nominal Voltage selected above. Values may be edited if a site-specific study requires different boundaries.

Shock Hazard Present?

Limited Approach Boundary

Restricted Approach Boundary

Prohibited Approach Boundary

🔥 Arc Flash Hazard Analysis

⚠️ WARNING: Arc flash incident energy >40 cal/cm² is PROHIBITED - work must not proceed until energy is reduced.

Arc Flash Label Present?

Arc Flash Boundary (ft)

Incident Energy (cal/cm²) *

PPE Category *

Working Distance (in)

Fault Current (kA)

Clearing Time (cycles)

Hazard Risk Category

Arc Flash >40 cal/cm²?

🛡️ PPE Requirements

Arc Flash PPE

Arc-Rated Clothing

Arc Rating Min (cal/cm²)

Arc-Rated Face Shield

Arc Flash Suit Hood

Safety Glasses

Arc-Rated Hard Hat

Shock Protection PPE

Voltage-Rated Gloves

Leather Protectors

Voltage-Rated Tools

Insulated Matting

Hearing Protection

Voltage-Rated Sleeves

📋 Safe Work Practices

Qualified Person Assigned?

Job Briefing Conducted?

Test Equipment Verified?

Barricades/Signs in Place?

Emergency Procedures Reviewed?

Safety Watch/Alerter Assigned?

Single-Line Diagram Reviewed?

Rescue Equipment Available?

Second Qualified Person Present?

✓ Verification Checks

Correct Circuit Identified?

LOTO Attempted First?

Proper Test Equipment Available?

Approach Boundaries Marked?

Non-Conductive Ladders Only?

Conductive Items Removed?

Illumination Adequate?

Working Space Clear?

⚠️ Additional Hazard Categories

Check all that apply - additional permits may be required:

Working at Heights

Confined Space

Wet/Damp Location

Outdoor/Weather

📝 Hazard Mitigation Table

Task	Hazard	Mitigation

✍️ Authorization

Qualified Person Signature *

Responsible Supervisor *

Area Operator

Permit Start Time *

Permit Expiration Time *

Crew Acknowledges Stop Work?