Download Electrical Qualified Person

Electrical Qualified Person
Name: _______________________________________
Date: _________
A qualified person must be trained and familiar with the construction and operation of equipment and must
be able to recognize and avoid electrical hazards that might be present. This is a combination of the
person’s education and experience, on-the-job training at the current employer for the type of equipment
encountered, and safety-related information and training regarding hazards and protective equipment.
Indicate the current level of license/education or experience achieved to date.
Electrical License
Electrical-Related Education
Master Electrician License
Associate’s degree (2-year) in an
Journeyman Electrician License
electrical field from a trade/technical school
Journeyman Lineman
or community college
Apprentice Program in electrical field
Bachelor’s degree (4-year) in an
electrical engineering
Granted by:
Virginia
Other:_____
Other (specify): ________________
License is:
current
expired
Electrical experience: ____ years
Indicate training and/or information that the employee has been provided relating to
electrical work tasks and potential exposures.
Electrical hazards of welding
Proper care, maintenance, and use of
Safe approach distances to overhead
electrical test equipment
energized conductors
Electrical hazards associated with
Electronic equipment testing protocols
industrial machinery being operated
EHSS Safety Training (instructor initial)
_____The effects of current flow and arcflash on the human body
_____Characteristics, selection, and use of
PPE for shock and arc-flash protection
_____Concept of approach boundaries,
including the flash-protection boundary
_____Hazards associated with testing
circuits and voltmeter care and inspection
_____How to establish an electrically safe
work condition (i.e. lockout/tagout)
_____Adult First Aid
_____Adult CPR (AED optional)
On-the-Job Skills/Knowledge
Testing for absence of voltage and what
to do if voltage is found
Installing and removing temporary
grounds and how to establish an equipotential zone
Employer policies regarding electrical
work
Equipment-specific training, such as
construction and operation from the
manufacturer
Other: ______________________
This employee has attended EHSS training as indicated above and it is current at this time.
Safety Representative Signature:
This employee has received on-the-job skills and knowledge and the employee is authorized to work on the
systems described on the back of this form (list on back of form).
Supervisor’s Signature:
I understand that I am expected to have the skills and knowledge indicated above. I agree to discuss any
work that is outside of my skills and knowledge with my supervisor or lead person.
Employee’s Signature: