BPA F 6410.42e CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

BPA F 6410.42e

CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

(01-2023)

OMB Control Number: 1910-XXXX

Page 1 of 3

Expiration Date: xx/xx/xxxx

Permit shall be posted on job site and retained for one year after job completion.
Instructions for each field can be found on pages 2 and 3 of this form.
1. Facility or Station:

2. Room or Area:

3. Contract Worker (Name)

4. Work Phone Number

5. Extended Duration

6. One-time Use Only

7. Contract Supervisor (Name)

8. Work Phone Number

9. Start Date

10. Expiration Date

11. Description of work to be done:

12. Description of circuit or equipment:

13. Justification for why equipment cannot be de-energized:

Shock Hazard Analysis
14. Maximum Voltage:

15. Limited Approach Boundary:

17. Insulated Tools or Equipment Rating:

16. Minimum Approach Distance

18. Glove Rating or Class:

Arc Flash Hazard Analysis
19. Incident Energy Level (Cal/cm2)

20. Arc Flash Boundary

NOTE: unqualified workers may be escorted into the limited approach boundary, but may NOT enter the arc flash boundary without
all the proper PPE as required for the incident energy.
21. Arc Rated Clothing Worn:

22. ATPV Rating (Cal/cm2):

23. Safety Checklist: All items must be checked and discussed as part of the pre-job briefing. If any item cannot be met provide justification in the
space provided. Any items not checked will require Supervisory and Organizational Manager approval prior to work.
All Workers involved must be trained, qualified, and have full knowledge of equipment being worked on.
A minimum of one additional Qualified Electrical Worker is required. This person must be able to de-energize all power sources and have
immediate access to a telephone or radio to call EMS in case of emergency
Necessary personal protective equipment to safely perform the assigned task.

Removal of all jewelry and metal apparel.

Means employed to restrict the access of unqualified persons from the work
area (barricades/warning signs):

Documented job briefing including discussion of any
additional job-specific hazards.

Electrical Contact Accident Protocol reviewed and available:
Justification:
Do you agree the above described work can be done safely? (If no, return to requester)

Yes

No

24. Contract Qualified Electrical Worker performing Hazard Analysis (Name)

a. Date

25. BPA District Engineer / Substation Operations Representative (Name)

a. Date

Authorization (must be signed prior to start of work)
26. COTR (Name)

a. Date

27. Prime Contract Project Manager (Name)

28. Supervisor (Name)

a. Date

a. Date

29. Additional Workers Involved
Printed or typed name(s)

Signature(s)

Date(s)

File Code: FE-1100; Retention: Destroy when no longer applicable

BPA F 6410.42e
(01-2023)

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

Page 2 of 3

OMB Control Number: 1910-XXXX
Expiration Date: xx/xx/xxxx

Instructions: BPA’s intent of the Contract Energized Electrical Work Permit is to ensure that all work is
conducted de-energized whenever possible.
1.
Facility/Station: This is the general location of the work. Example: substation name, building name, etc.
2.

Room/Area: This is a more specific description of where the work is taking place. Example: Relay house 1,
Control House, Second floor hallway etc.

3.

Contract Worker: Enter the person’s name who will be performing the work.

4.

Work Phone Number: Enter the phone number to be used to contact the person performing the work. It
may be the supervisor’s phone number if the employee does not have a phone.

5.

Extended Duration: Check this box if the work will be occurring for more than one work day. DO NOT FILL
OUT A SINGLE PERMIT FOR MULTIPLE JOBS. Each job requiring a permit will need a separate permit.
Example: replacing or adding several molded case breakers into a single panel requires 1 permit. Replacing or
adding molded case breakers into separate panels requires a permit for each panel.

6.

One Time Use: Check this box if the work is expected to be completed on the same day. Note if the work
extends beyond a single day go back and check the extended duration box and note that the work was
extended. A new form does not need to be completed.

7.

Contract Supervisor: The name of the direct supervisor of the contract worker.

8.

Work Phone Number: The Direct Supervisor’s phone number. This may be the same as the number entered
in #4 if the supervisor’s number was given there.

9.

Start Date: The date that the actual work requiring the permit started.

10.

Expiration Date: This is the date when the work is expected to end. If the work continues past the expected
date a new date may be entered by hand. The permit does not actually expire until the work is deemed
complete.

11.

Description of work to be done: Self-explanatory. Enter as much information about the scope of the job
requiring the permit.

12.

Description of circuit/equipment: Enter as much information as needed to understand the
limits/parameters of the work. Example: Replacing bad order ACB in 480V panel PL-4.

13.

Justification of why equipment cannot be de-energized: This should be as detailed as possible. It should
not read “Not feasible”, “Operator said no”, “Dispatch would not allow”. Example: De-energization of the
station service panel YP-2 would require the entire station to be run on batteries. On the last battery
maintenance cycle the station batteries were found to be in need of replacement and should only be relied
upon for emergencies. Batteries are scheduled to be replaced but this work cannot wait for the replacement
due to critical loads.

14.

Maximum Voltage: This is the highest nominal voltage rating of the equipment covered under the permit. It
is usually found on the arc flash label. If the work involves a transformer, then the high side voltage should
be noted.

15.

Limited Approach Boundary: This is the distance which unqualified individuals must be kept from crossing
without an escort. It protects against shock hazard. This or the Arc Flash Boundary (whichever is greater) will
be used to determine your barricade distance.

16.

Minimum Approach Distance: The distance which qualified individuals must maintain without one of the 5
provisions in APM Rule M-1 being in place.

17.

Insulated Tools or Equipment Rating: This is the voltage rating of insulated tools or barriers used to
prevent contact with energized parts.

18.

Glove Rating or Class: This is the rating of the glove the worker is using to prevent accidental contact.
Remember there are different ratings for AC and DC. Also, if the glove is used without a leather protector it
must be de-rated by 50% or 1 voltage class, whichever is greater. The glove must also be electrically retested
before being used at full voltage and may not be used if there is a possibility of puncture or damage.

19.

Incident Energy (Cal/cm2): This is the calorie rating of the circuit being worked. It can be found on the
affixed label or acquired from the BPAHotStickCurves (Dynamic Use) spreadsheets.

BPA F 6410.42e
(01-2023)

U.S. DEPARTMENT OF ENERGY – BONNEVILLE POWER ADMINISTRATION (BPA)

CONTRACT ENERGIZED ELECTRICAL WORK PERMIT

Page 3 of 3

OMB Control Number: 1910-XXXX
Expiration Date: xx/xx/xxxx

20.

Arc Flash Boundary: This is the distance that the incident energy is 1.2 calories/cm2 or less. It can be found
on the affixed label. It is the second factor used in determining where the barricade distance must be
established to prevent unqualified workers from entering into the work zone. NOTE: unqualified workers may
be escorted into the limited approach boundary but may NOT enter the arc flash boundary without all of the
proper PPE as required for the incident energy.

21.

Arc Rated Clothing Worn: this is the clothing that will be required to meet or exceed the incident energy
level. If layering is used list all layers of clothing.

22.

ATPV Rating (Cal/cm2): List the rating of the clothing worn. If layering is performed list the total APTV
rating of the layered system or the rating of the outermost layer if it exceeds the incident energy. This rating
must meet or exceed the incident energy.

23.

Safety Checklist Items: All items must be checked and discussed as part of the pre-job briefing. If any item
cannot be met provide justification in the space provided. Any items not checked will require Supervisory and
Organizational Manager approval prior to work.

24.

Contract Qualified Electrical Worker (QEW) Performing Hazard Analysis: This is the signature block
for the QEW who performed the Shock and Arc Flash Hazard analysis. It does not have to be the individual
who will be performing the work.

25.

BPA District Engineer or Substation Operations Representative: This is the signature of the person who
confirmed that the work must be performed energized.

26.

COTR: This is the signature of the Contract Officer’s Technical Representative for the contract.

27.

Prime Contract Project Manager: This is the project manager for the prime contractor for the project.

28.

Supervisor: This is the signature of the supervisor for the person performing the work. This signature may
be signed as verbal consent given. This cannot be given as a third party approval. If the same individual as
block #27, write in “same as #27”.

29.

Additional Workers Involved: List all workers who will be inside of the arc flash boundary while the work is
being performed. Each name listed shall also have a signature that the individual agrees with the information
on the form. Any worker not wishing to sign may not be allowed into the arc flash boundary until the work
has been placed into an electrically safe work condition.

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to ensure the safety of BPA’s contract workers. The data you supply will be used by BPA to validate
equipment cannot be de-energized by BPA engineers or substation operators before a contractor is allowed to work on energized
equipment. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining that data needed, and completing and
reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to Office of the Chief Information Officer, Enterprise Policy Development & Implementation Office, IM-22,
Paperwork Reduction Project (OMB control number 1910-XXXX), U.S. Department of Energy, 1000 Independence Ave SW,
Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (OMB control
number 1910-XXXX), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for
failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of
Management and Budget (OMB) before undertaking a collection of information directed to 10 or more persons of the general public,
including persons involved in or supporting the operations of Government-owned, contractor-operated facilities.
Submission of this data is mandatory.