Hazardous Energy Isolation

• Site conducted

  Select

• Date of audit

  Date

• Name of Auditor

• Location
  Address

• Risk Assessment Completed

  Yes

  No

  N/A

• LOTO Sheet Filled Out

  Yes

  No

  N/A

Requirements for Energy Isolation

• Trade Locks in Place

  Yes

  No

  N/A

• Personal Lock in Place (Name, Company, Contact Number if Business Partner)

  Yes

  No

  N/A

• Is personal lock different color than trade locks

  Yes

  No

  N/A

• Can the lock be replaced as soon as possible

  Yes

  No

  N/A

• Has the system been verified as de-energized

  Yes

  No

  N/A

• Tag Explaining Reason for Lockout (this may be an FPC board or lockout sheet)

  Yes

  No

  N/A

• If electrical lockout, is the lockout at the power source

  Yes

  No

  N/A

• Was the job stopped and supervision notified

  Yes

  No

  N/A

Live work and testing

• Have exclusion zones been established

  Yes

  No

  N/A

• Is display sign on equipment stating "equipment being tested"

  Yes

  No

  N/A

• Did you utilize stop unsafe work authority

  Yes

  No

  N/A