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Electrical Qualification and On the Job Training (OJT) Form
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____________________________________________________________________________________________
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Required fields are marked with an *
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*Title:
*Division:
*Supervisor:
*Working Location(s):
*Names of workers to be authorized:
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1. DESCRIPTION OF WORK:
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*Type(s) of equipment to be worked on:
*Tasks that can expose the worker to an electrical hazard:
Tools, meters, test instrument or other equipment used while performing these tasks:
Describe any non-elecrical work, other than testing, measurement,
probing, troubleshooting, calibrating, inspecting that will be done
while the equipment is energized with the covers removed:
Unusual conditions:
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2. TASK CATEGORIES (check all that apply):
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LOTO Zero-Voltage Verification ( < or = 120V):
LOTO Zero-Voltage Verification ( > 120V):
Testing and trouble shooting of energized equipment ( < 120V):
Testing and trouble shooting of energized equipment ( > 120V and < 480V):
Testing and trouble shooting of energized equipment ( > 1000V):
Other:
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3. EQUIPMENT:
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Supply Voltage (circuit) rating (or range of ratings for multiple equipment):
Maximum supply current (circuit) rating (or range of ratings for multiple equipment):
Capacitors inside equipment, (volts, joules of largest capacitor):
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4. ARC FLASH HAZARD:
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*Incident Energy:
Arc Flash Protection Boundary:
*Describe Arc flash PPE Selection decision process and Arc Flash Protection Boundaries for various conditions:
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5. HOW WILL APPROACH BOUNDARIES BE ESTABLISHED AND MANTAINED?
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6. SPECIFIC SAFETY PRACTICES/PROCEDURES TO BE FOLLOWED:
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7. DESCRIBE ANY POTENTIAL HOLD POINTS:
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8. QUALIFICATIONS/EXPERIENCE REQUIREMENTS:
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After submitting this form you will receive a confirmation email. Make sure you correctly fill out the email field below as this will be used for your
confirmation email. If you do not receive this email, please submit a new permit, or call Keith Gershon (510) 486-4694.
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Submitted by: (Name)
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E-mail: (example@lbl.gov)
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