Information
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Employee FIRST NAME/LAST NAME/TEMPLATE TITLE
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Client Name / Rig Name
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Conducted on
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Location
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Permit valid at?
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Description of work?
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Energy Flow to be Controlled (Check all that apply)
- Chemicals
- Compressed Air
- Control Power
- Electricty
- Hydraulic
- Moving Parts
- Natural Gas
- Pneumatic
- Steam
- Water
- Gravity
- Other
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1. Completed LOTO Permit
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2. Identified all energy sources
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3. Notified affected employees
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4. The Equipment was removed from service
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5. The Equipment was isolated
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6. Reduce equipment to zero energy state
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7. Applied lockout devices ( Tags / Locks )
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8. Tested and turned on equipment to ensure it has been isolated
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Verification performed by
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9. Performed task properly and safely
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10. Restored equipment to operational state
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11. Returned all lockout devices to lockout kit
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12. Notifed authorizing party when equipment is available for service
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13. Employee was referring to latest SOP
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14. SOP was used and incorporated in the LOTO Permit
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Competency Evaluation was Performed by:
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I confirm that the employee/contractor has demonstrated competency and understanding of the BOS LOTO process found in the HSE Permit to Work Standard.
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Employee/Contractor is:
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Evaluators Name
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Employee/Contractors Name
