Information
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Title
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Prepared by:
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Certificate No:
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Project:
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Date:
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Site:
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Purpose of the Isolation
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Method Statement No:
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Risk Assessment No:
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Switching Coordinator:
Safe Isolation Procedure
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Isolation agreed with the client?
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STOP! Do not carry out Isolation. Agree with client first.
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Authorised by:
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Is it Safe to Isolate?
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STOP! DO NOT CARRY OUT ISOLATION, ensure that risk assessment have been carried out and risk reduced to medium level to allow safe isolation to be carried out.
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Voltage present at supply terminals?
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What procedure have been followed to ensure that the supply is isolated and can not be reinstated?
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Load Removed?
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STOP! Remove Load before proceeding.
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Means of isolation OPENED and LOTO?
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STOP! Ensure that the supply is Locked Off Tagged Off before proceeding
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Correct operation of Voltage detection instrument proved against known source of supply?
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Prove correct operation of the Voltage detection instrument !
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Danger Voltage present between Line & Line?
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Isolation UNSATISFACTORY ! Repeat all steps again!
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Danger Voltage present between Line & Neutral?
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Isolation UNSATISFACTORY ! Repeat all steps again!
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Danger Voltage present between Line & Earth?
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Isolation UNSATISFACTORY ! Repeat all steps again!
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Danger Voltage present between Neutral & Earth?
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Isolation UNSATISFACTORY ! Repeat all steps again!
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Operation of Voltage detection instrument proved again against known source of supply?
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Prove correct operation of the Voltage detection instrument !
Isolation Details
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Equipment/Circuit/Area Isolated:
Item
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Details:
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Point of Isolation:
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LOTO Method:
- Lock
- Tag
- Seal
- N/A
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Lock No:
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Re-energise prevention method used:
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Photo:
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Fuses Removed?
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Fuses kept by?
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Re-energise prevention method used:
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Circuits Proven DEAD?
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Isolation UNSATISFACTORY ! Repeat Isolation Procedure.
Confirmation
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Recommendations and additional notes:
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Photo
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Photo
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Isolation carried out & confirmed by:
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Select date
