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Lock-out Tag-out Lock Removal Authorisation Form
Lock-out Tag-out Lock Removal Authorisation Form
David Lucioni

Lock-out Tag-out Lock Removal Authorisation Form

In the event that a lock is left on an energy isolating device and the person to whom the lock belongs has not left the site, the person must be located to remove the lock. If it has been verified that the owner of the lock has left the site, this form must be completed and signed by the supervisor removing the lock. This form serves as evidence that the lock has been removed lawfully and is therefore NOT an act of gross misconduct

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Free Lock-out Tag-out Lock Removal Authorisation Form Checklist

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Title Page

  • Conducted on

  • Prepared by

  • Cell No.

  • Machine Asset Number (CLxxxx)

Lock Removal Record:

  • What is the reason as to why the lock(s) must be removed?

  • Has an attempt been made to contact the lock owner by phone?

  • Has it been verified that the equipment is safe to operate?

  • Has the Plant Manager / Maintenance Manager approved the removal of the lock(s)?

  • Has the EHS Manager approved the removal of the lock(s)?

Investigation

  • What was the reason the lock owner failed to remove the lock(s)

Signatures

  • Supervisor Name:

  • Factory Manager / Maintenance Manager Name:

  • EHS Manager Name:

Lock-out Tag-out Lock Removal Authorisation Form
David Lucioni

Lock-out Tag-out Lock Removal Authorisation Form

In the event that a lock is left on an energy isolating device and the person to whom the lock belongs has not left the site, the person must be located to remove the lock. If it has been verified that the owner of the lock has left the site, this form must be completed and signed by the supervisor removing the lock. This form serves as evidence that the lock has been removed lawfully and is therefore NOT an act of gross misconduct

Use this Template
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.

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