Job Safety Plan
California State University, Chico
TO BE COMPLERED BY ELECTRICALLY QUALIFIED PERSON: (attach additional documentation as needed)
(1) Description of the Job:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
(2) Description of each individual task to be performed and identification of the electrical and other hazards associated
with each step of the task. (attach completed JSA):
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Use this section for notes and comments
____________________________________________________________________________________________
(4) Results of the shock risk assessment: (5) Results of the arc flash risk assessment:
• Electrical system nominal voltage:
____________________________ • Available incident energy level _________cal/cm²
• Limited approach boundary distance: or arc flash PPE category__________
____ft.____in • Arc flash boundary ______ ft _______in
• Restricted approach boundary distance: Appropriate arc flash and other personal protective
____ft.____in equipment required for the work to be performed:
• Appropriate shock and other personal protective _____________________________________________
equipment required for the work to be performed: _____________________________________________
_______________________________________ _____________________________________________
_______________________________________ _____________________________________________
_______________________________________ _____________________________________________
(6) Specific safe work procedure that may involve with individual task:
______________________________________________________________________________________________
______________________________________________________________________________________________
(7) Special precautions that may be necessary:
______________________________________________________________________________________________
______________________________________________________________________________________________
(8) Necessary energy source controls:
______________________________________________________________________________________________
______________________________________________________________________________________________
(9) Pre-Job Safety Briefing
______________________________________________________________________________________________
______________________________________________________________________________________________
I acknowledge that a pre-job briefing has been performed and that I understand this job safety plan and will comply
with all safety requirements.
Electrically Qualified Person Signature:
________________________________________________________________Date:____/____/____
Additional Workers Signatures:
________________________________________________________________Date:____/____/____
________________________________________________________________Date:____/____/____
NOTE: If scope of plan changes so must the Job Safety Plan- a new plan must be completed for different work.
Provide this form and all supporting documentation prior to work to Manager for filing, retain and have copy at
job site for the duration of work.
