Information

  • Customer's Name:

  • Site's Name:

  • Customer's Person in Charge:

  • SE Person in Charge:

  • IMPORTANT! The first 6 steps of this checklist must be completed, signed and visibly posted at the point of work BEFORE starting work.

  • PREPARATION STAGE

  • PREPARATION STAGE Checked and Signed by SE Person in Charge:

  • PREPARATION STAGE Remove the load Approved by Customer Person in Charge:

  • STEP 1. Remove the load

  • STEP 2. Separation (Dead)

  • STEP 3. Securing Isolation (locking in open position)

  • STEP 4. Verification of absence of voltage (VAV) * Note * All circuits are considered energized until verified.

  • STEP 4 Checked & Signed by SE Person in Charge:

  • STEP 5. Earthing (Grounding) and short-circuiting {Not mandatory below 1000v}

  • STEP 5 Checked & Signed by Customer Person in Charge:

  • STEP 6. Protect adjacent energized circuits

  • After even the shortest interruption of the work process (i.e. visit to restroom, lunch, etc), carry out a visual check to ensure all controls are in place – locks, tags, barriers and Earthing (Grounding) and short-circuiting for greater than 1000V.

  • All 6 STEPS Complete & Signed by:

  • INFO: Electrical Testing: Lock out all paths up and down stream of the equipment being tested to prevent back feed.

  • * SE Work Team (SE employees & Contractors) * “Sign In” {I have completed steps 0-6 , placed my lock on the lock out device and will now work de-energized}. All Signees:

  • * SE Work Team (SE employees & Contractors) * “Sign Out” {I have finished working de-energized , I have removed my lock from the lock device and I aware that the system is about to be re-energized}. All Signees:

  • STEP 7. Temporary release of LOTO

  • STEP 8. Release of LOTO - Re-energizing

  • STEP 8 Checked & Signed by SE Person in Charge:

  • STEP 8 Checked & Signed by Customer Person in Charge

Section II

  • Add location
  • Select date

  • Add signature

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.