JHG Isolation Verification and Witnessing Checklist

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

General Isolation Information

• Isolation Plan No.

• Location of Isolation Board:

• Isolation Contact Person:

• Isolation Contact Person Phone No.:

• Description of work as shown on the Isolation Plan:

• Issue Date of Isolation Plan:

• John Holland Supervisor:

• John Holland Supervisor Contact No.:

• JHG Isolation Verifier and Witness Name:

• JHG Isolation Verifier and Witness Contact No.:

Isolation Checklist

• Has JHG requested the Isolation and is the Isolation Plan available at the Isolation Board?

  Yes

  No

  N/A

• Has the JHG Supervisor informed the Client that the work crew will be working under the Isolation?

  Yes

  No

  N/A

• Is the Isolation Plan correct for the task as detailed in the Task Risk Assessment?

  Yes

  No

  N/A

• Are all required items locked out / isolated as per the Isolation Plan in order to perform the works safely?

  Yes

  No

  N/A

• Has the Isolation been witnessed and tested for dead by an authorized JHG verifier?

  Yes

  No

  N/A

• Are the Equipment Locks installed as per the Isolation Plan with the lock numbers detailed?

  Yes

  No

  N/A

• Are the Equipment Lock Keys visible within the Isolation Board?

  Yes

  No

  N/A

• If any answers are not YES, do not proceed to witness personnel locking onto the Isolation Board.

JHG Isolation Verifier and Witness Signoff

• I have communicated the Isolation Plan to the work force and I accept that the Isolation is in place to the best of my knowledge, as per the Isolation Plan. I have witnessed the work crew place their Personal Red Locks onto the Isolation Board.

• Isolation Verifier and Witness Person:

• Select date

  Date

• JHG Isolation Verifier and Witness:

  Sign

Workforce Signoff

• The Isolation Plan has been explained to me and I am satisfied that the Isolation will protect me from potential hazardous energy sources while I am conducting the task specified in the Task Risk Assessment.

• Company:

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