Powerline Safety Acknowledgement Form
Complete this form to confirm understanding of powerline hazards and required safety precautions before work begins.
Worker Details
Worker's Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Employer / Company Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Work Site and Task Information
Work Site / Location
*
Date of Work or Acknowledgement
*
-
Month
-
Day
Year
Date
Task or Activity Description
*
Equipment, Tools, or Vehicle Involved
Hand tools
Ladder
Bucket truck
Crane
Aerial lift
Excavator
Pickup truck
Other
Will you be working near overhead or nearby powerlines?
*
Yes
No
Estimated Distance to Powerlines (feet)
Safety Awareness and Hazard Review
Required minimum clearance from powerlines understood?
*
Yes
No
Unsure
Is a spotter/banksman or supervisor required for this task?
*
Yes
No
Unsure
Were controls to de-energize or reroute the powerline discussed?
Yes, de-energizing discussed
Yes, rerouting discussed
No discussion yet
Not applicable
Have equipment height limits and safe approach distances been checked?
*
Equipment height limits checked
Safe approach distances confirmed
Equipment fitted with height restrictor or limiter
Not yet checked
Do you know what to do if contact with a powerline occurs?
*
Yes, trained on emergency steps
Not sure
No
Emergency and Acknowledgement
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Acknowledgement
Should be Empty: