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Audit

Scope of Works

Permit valid from
Permit valid to
Isolation/Lock Out/Tagout

Are the following equipment/materials isolated or locked out before any maintenance or installation work:

Electricity

Point of Isolation

Gas

Point of Isolation

Water

Point of Isolation

Air

Point of Isolation

Fire Alarm System

Point of Isolation

Fire Sprinkler System

Point of Isolation

Precautions
Click + to list precautions

Enter details here

Tools and Equipment
Click + to list tools and equipment to be used

Enter details here (e.g. Scaffold, PPE, Welding sets, 110V Tools etc.)

Completion
Full Name and Signature of Contractor Site Supervisor
Full Name and Signature of Client Authorizing Person

Permit to Work Template for Maintenance Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 67

All equipment should be isolated, locked out and tagged out to prevent accidents like electrocution, explosion, cuts, etc. Use this checklist as a guide to which equipment or materials should be locked out before any maintenance work. Record and take a photo of the point of isolation. List the precautions, tools and equipment to be used during the procedure.

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Audit

Scope of Works

Permit valid from
Permit valid to
Isolation/Lock Out/Tagout

Are the following equipment/materials isolated or locked out before any maintenance or installation work:

Electricity

Point of Isolation

Gas

Point of Isolation

Water

Point of Isolation

Air

Point of Isolation

Fire Alarm System

Point of Isolation

Fire Sprinkler System

Point of Isolation

Precautions
Click + to list precautions

Enter details here

Tools and Equipment
Click + to list tools and equipment to be used

Enter details here (e.g. Scaffold, PPE, Welding sets, 110V Tools etc.)

Completion
Full Name and Signature of Contractor Site Supervisor
Full Name and Signature of Client Authorizing Person