AGL 2022 - Isolation certificate

• Site name

  Select

• Conducted on

  Date

• Prepared by

• Client

• Engineer signature

  Sign

• Supervisor signature

  Sign

• Name of person who ordered work

Equipment details

• Time of isolation?

  Date

• Location of isolation?

• Equipment/circuit to be isolated?

• Safety locks fitted?

  Yes

  No

  N/A

• Safety lock location?

• Caution notice location?

• Notes?

• Are the works on the relevant circuit complete?

  Yes

  No

  N/A

• Have all the relevant inspections and tests been carried out?<br>

  Yes

  No

  N/A

• Visual inspection <br>

  Good

  Fair

  Poor

  N/A

• IR Test <br>

  Yes

  No

  N/A

• R1+R2 Test<br>

  Yes

  No

  N/A

• Re-energised on:

  Date

• Engineer signature

  Sign

• Supervisor signature

  Sign