LIFE’S CHECKLISTS · FREE WORKSHEET
Room and circuit map
Use with the safe breaker-mapping guide. Labels do not prove wires are safe to touch.
First read the completed example. Then write your own answers in the blank sections. If you do not know an answer, write what you need to ask. Official applications may require their own forms.
Completed example
This is a fictional practice entry. Write your own details in the blank sections below.
- Breaker label / number
- Example label: Kitchen 1
- Lights / outlets affected
- Counter outlet confirmed
- Exact room location
- Left of kitchen sink
- Test date
- October 23
- Uncertain items
- Other kitchen outlets not tested; leave unconfirmed
Date: ____________________
Circuit 1
Lights / outlets affected
Exact room location
Test date
Uncertain items
Circuit 2
Lights / outlets affected
Exact room location
Test date
Uncertain items
Circuit 3
Lights / outlets affected
Exact room location
Test date
Uncertain items
Circuit 4
Lights / outlets affected
Exact room location
Test date
Uncertain items
Circuit 5
Lights / outlets affected
Exact room location
Test date
Uncertain items
Circuit 6
Lights / outlets affected
Exact room location
Test date
Uncertain items
Notes: