• Document No.

  • Division

  • Location: (Roosevelt, Piceance, Orangeville, LaBarge, Farmington, Bakken, Trinidad)

  • Employee Name:

  • Report type: (LOTO, Safety Audit, Hot Work, JSA, Electrical JSA)

  • Facility/ Site Name

  • Conducted on


  • Reason for permit:

  • Type of report:

  • Can this work be performed de-energized

  • Voltage Levels involved

  • Equipment Type:

  • Primary Disconnect

  • What is the voltage?

  • What is the amperage?

  • Hazard Category:

  • Is all Category PPE Present?

  • Shock Boundary

  • Arc Flash Boundary

  • Unqualified Persons Boundary

  • Single Line Diagrams

  • Voltage Testing Equipment Verified

  • At what Voltage was equipment verified?

  • Is Voltage testing equipment rated for the maximum voltage on job site?

  • What is the maximum rating of test equipment, in volts?

  • Critical Verification Voltage Test Points? List all that apply.

  • Insulated Tools required?

  • How will this work be performed?

  • LOTO?

  • Special LOTO Requirements?

  • Signatures of Qualified Persons

  • Qualified Person
  • Qualified Person

  • Company

  • Minimum PPE Requirements:

  • Hazard identification and safety briefing/discussion:

  • List all Identified Hazards and action taken to mitigate risk:

  • Identified Hazard
  • Identified Hazard:

  • Remedy to mediate risk of hazard:

  • XTO Safety Handbook references: (List all that apply, include page numbers, or N/A if not applicable)

  • Signatures of all attendees:

  • Attendees
  • Attendee Signature

Post-Job Debriefing:

  • Were any additional hazards encountered during the course of this work?

  • List additional hazards:

  • Comments:

  • XTO Representative:

Safety Audit

  • Personal Protective Equipment: (Check all that apply)

  • Work Area - General: (Check all that apply)


  • Is LOTO being used?

  • Is LOTO being used properly?

Hazardous Materials

Electrical Safety

  • Electrical Safety: (Check all that apply)

  • Was selected component(s) de-energized prior to work being performed?


  • Lifting: (Check all that apply)

Working Above 4' / Ladder

  • Working at height: (Check all that apply)

  • Was work to be performed at a height >6ft?

  • Is fall protection being used?

Hot Work

  • Purpose for Permit:

  • Hot Work conditions: (Check all that apply)

  • List any corrective actions taken:

  • Comments:

  • XTO Representative


  • List all equipment to be locked and tagged:

  • Equipment Item
  • What type of energy source are you eliminating?: Select one

  • Effected Equipment Category

  • Select system

  • Please enter description:

  • Select System

  • Please enter description:

  • Effected Equipment Category

  • Select System

  • Please enter description:

  • Please enter description:

  • Select system:

  • Please enter description:

  • Physical Lock Location:

  • Isolated Position

  • Tagged?

  • Locked?

  • Lock Number?

  • Lock/Tag Installed Date and Time

  • Lock/Tag Removed Date and Time:

Safe to perform verification: (all effected parties must sign before work can begin)

  • By signing below I certify that I have examined and tested all energy control devices, and that the equipment / systems are isolated, decontaminated, and safe to perform the work indicated.

  • verification signature
  • Signature

Post Work - Safe to return to service: (All effected parties on site must sign prior to work beginning)

  • By signing below I certify that I have examined the equipment / system and it is mechanically / electrically complete and safe to return to service.

  • verification signature
  • Signature

Hot Work

  • Enter readings to document acceptable levels: (Initial check prior to work, and subsequent test if conditions have changed or you have left the area)

  • Atmosphere Test
  • Time of test

  • Oxygen:

  • Combustible Gas: (LEL)

  • Hydrogen Sulfide:

  • Carbon Monoxide:

  • Other:

  • Special Precautions: (Check all that apply)

  • Hot Work: (Check all that apply)

  • Enter information for site personnel:

  • Operating Personnel Approval
  • Company/Contractor or employee

  • Assigned Task of Employee

  • Signature

  • Are Hazardous materials being used?

  • List Hazardous Materials:

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