MMK Isolation Verification Assessment

• Site conducted

  Select

• Equipment No:

• Conducted on

  Date
• Location
  Address

• Checked for the availability and condition of required PPE (gloves, safety glasses, etc.).?

  Yes

  No

  N/A

• Only qualified and competent employees apply LOTO procedures ?

  Yes

  No

  N/A

• Equipment Isolation have been proven lock, tag and tested ?

  Yes

  No

  N/A

• All persons involved in the task has personal locks and tags attached to the Scissor Hasp or Lock Box ?

  Yes

  No

  N/A

• Entire team has performed a field level risk assessment (FLRA) ?

  Yes

  No

  N/A

• Verify the task is communicated within the team ?

  Yes

  No

  N/A

• Equipment Isolation is verified by a Verifier ?

  Yes

  No

  N/A

Signature

• Supervisor has checked to ensure the life saving controls are in place?

  Yes

  No

  N/A

• Equipment safe for Maintenance ?

  Safe

  At Risk

  N/A

• Isolator name:

  Sign

• Inspected by:

  Sign