6354LOTOTemplate

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

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• 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:

  Select Safety Glasses Nitrile Gloves Latex Gloves Electrical Gloves Leather Gloves Arc Rated Clothing Arc Rated Hard Hat and Faceshield Hard Hat Hearing Protection Face Shield Arm Sleeves Tyvek Coverall Arc Flash Suit Safety Toe Boots Other (Provide Details)

  • Safety Glasses
  • Nitrile Gloves
  • Latex Gloves
  • Electrical Gloves
  • Leather Gloves
  • Arc Rated Clothing
  • Arc Rated Hard Hat and Faceshield
  • Hard Hat
  • Hearing Protection
  • Face Shield
  • Arm Sleeves
  • Tyvek Coverall
  • Arc Flash Suit
  • Safety Toe Boots
  • Other (Provide Details)

• Additional PPE Details:

• Picture of Isolation Location

  Media

• Describe location of isolation point.

• Type of Energy

  Select Electricity Steam Water Gas Air Pressure Hydraulic Gravity Other (Must Enter in Details Below)

  • Electricity
  • Steam
  • Water
  • Gas
  • Air Pressure
  • Hydraulic
  • Gravity
  • Other (Must Enter in Details Below)

• Provide details

• Equipment Needed

  Select Lock Hasp Cable Lock Gate Valve Cover Butterfly Lockout Ball Valve Lockout Breaker Lockout Universal Valve Lockout Other (Provide Additional Details)

  • Lock
  • Hasp
  • Cable Lock
  • Gate Valve Cover
  • Butterfly Lockout
  • Ball Valve Lockout
  • Breaker Lockout
  • Universal Valve Lockout
  • Other (Provide Additional Details)

• 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.