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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: