Isolation Verification System Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Isolation Information

• Isolation Plan #:

• Equipment to be Isolated:

• Plant Area:

• Job Description:

Isolating Device ID

• Isolating Device A Description:

• Device A has been locked in a safe position?

  Yes

  No

  N/A

• Device A Isolation has been verified?

  Yes

  No

  N/A

• Device A Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolation Device B Description:

• Device B has been locked in a safe position?

  Yes

  No

  N/A

• Device B Isolation has been verified?

  Yes

  No

  N/A

• Device B Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolation Device C Description:

• Device C has been locked in a safe position?

  Yes

  No

  N/A

• Device C Isolation has been verified?

  Yes

  No

  N/A

• Device C Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolation Device D Description:

• Device D has been locked in a safe position?

  Yes

  No

  N/A

• Device D Isolation has been verified?

  Yes

  No

  N/A

• Device D Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolation Device E Description:

• Device E has been locked in a safe position?

  Yes

  No

  N/A

• Device E Isolation has been verified?

  Yes

  No

  N/A

• Device E Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device F Description:

• Device F has been locked in a safe position?

  Yes

  No

  N/A

• Device F Isolation has been verified?

  Yes

  No

  N/A

• Device F Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device G Description:

• Device G has been locked in a safe position?

  Yes

  No

  N/A

• Device G Isolation has been verified?

  Yes

  No

  N/A

• Device ag a isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device H Description:

• Device H has been locked in a safe position?

  Yes

  No

  N/A

• Device H Isolation has been verified?

  Yes

  No

  N/A

• Device H Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device I Description:

• Device I has been locked in a safe position?

  Yes

  No

  N/A

• Device I Isolation has been verified?

  Yes

  No

  N/A

• Device I Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device J Description:

• Device J has been locked in a safe position?

  Yes

  No

  N/A

• Device J Isolation has been verified?

  Yes

  No

  N/A

• Device J Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device K Description:

• Device K has been locked in a safe position?

  Yes

  No

  N/A

• Device K Isolation has been verified?

  Yes

  No

  N/A

• Device K Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device L Description:

• Device L has been locked in a safe position?

  Yes

  No

  N/A

• Device L Isolation has been verified?

  Yes

  No

  N/A

• Device L Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device M Description:

• Device M has been locked in a safe position?

  Yes

  No

  N/A

• Device M Isolation has been verified?

  Yes

  No

  N/A

• Device M Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device N Description:

• Device N has been locked in a safe position?

  Yes

  No

  N/A

• Device N Isolation has been verified?

  Yes

  No

  N/A

• Device N Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device O Description:

• Device O has been locked in a safe position?

  Yes

  No

  N/A

• Device O Isolation has been verified?

  Yes

  No

  N/A

• Device O a isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device P Description:

• Device P has been locked in a safe position?

  Yes

  No

  N/A

• Device P Isolation has been verified?

  Yes

  No

  N/A

• Device P Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device Q Description:

• Device Q has been locked in a safe position?

  Yes

  No

  N/A

• Device Q Isolation has been verified?

  Yes

  No

  N/A

• Device Q Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device R Description:

• Device R has been locked in a safe position?

  Yes

  No

  N/A

• Device R Isolation has been verified?

  Yes

  No

  N/A

• Device R Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device S Description:

• Device S has been locked in a safe position?

  Yes

  No

  N/A

• Device S Isolation has been verified?

  Yes

  No

  N/A

• Device S Isolation has been tested for dead?

  Yes

  No

  N/A

• Isolating Device T Description:

• Device T has been locked in a safe position?

  Yes

  No

  N/A

• Device T Isolation has been verified?

  Yes

  No

  N/A

• Device T Isolation has been tested for dead?

  Yes

  No

  N/A

Group Isolation Board

• Isolation Board #:

• Yellow Equipment Lock Keys are positioned within the Isolation Board?

  Yes

  No

• Isolation Plan Checklist is clearly visible within the Isolation Board?

  Yes

  No