Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

undefined

  • Equipment Name

  • Asset Identification:

  • Building

  • Room

Lockout Procedure

  • The authorized employee or supervisor must notify people affected by a shutdown that a loss of service will occur and provide the expected start and duration of the project and a description of all systems shutdown. Sufficient lead time should be provided to allow affected areas to prepare for shutdown.

  • Number of Locks Needed

  • Lockout Procedure
  • Required Personal Protective Equipment:

  • Additional PPE Details:

  • Picture of Isolation Location

  • Describe location of isolation point.

  • Type of Energy

  • Provide details

  • Equipment Needed

  • If Other, Provide Details:

  • Directions for locking isolation point:

  • Method for verifying isolation:

Returning to Service

  • When returning equipment to services, verify that all tools, equipment, and other objects are removed from the work area. Notify all authorized and affected employees of impending start-up. Remove locks and open isolation points in reverse order. Reactivate equipment according to established start up procedure.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.