Regan McCarthy

Contractor Lockout Permit

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Use this Template

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Title Page

Site conducted
Line/Area
Machine Name/PF Number
Conducted on
Prepared by
Location
Personnel

Energy Type
- Electrical
- Pneumatic
- Inertia/Gravity
- Hydraulic
- Steam
- Water
- Mechanical
- Chemical
Energy Source Description
Lockout Point Location
Method/Lockout Device
Picture of Lockout Point
Is there any stored energy?
Type(s) of stored energy
- Battery
- Capacitor
- Gravitational
- Flywheel
- Spring-Loaded
- Counter Weights
- Pressure
- Thermal
Method to dissipate/restrain
Picture

Regan McCarthy

Contractor Lockout Permit

Use this Template

Print as PDF

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.