Information

  • Responsibilities for all aspects of a LOTO to be performed must be agreed upon and documented by all affected parties.
    LOTO which involves a utility disconnect will be classified as Complex LOTO (use Complex LOTO Procedure Sheet).
    LOTO which requires procedures for LOTO continuity across shifts will be classified as Complex LOTO (use Complex
    LOTO Procedure Sheet).
    LOTO which requires LOTO by other parties (e.g., customer, subcontractors, other contractors) will be classified as
    The 1st section of this checklist must be completed,
    signed and visibly posted at the point of work
    !! BEFORE STARTING WORK!!
    Complex LOTO (use Complex LOTO Procedure Sheet).

  • Customer's Name:

  • Site's Name:

  • Customer's Person in Charge:

  • SE Person in Charge:

LOTO CHECKLIST

  • The 1st section of this checklist must be completed,
    signed and visibly posted at the point of work
    !! BEFORE STARTING WORK!!

  • STEP 1: PREPARATION STAGE

  • PREPARATION STAGE (Selected and approved (signed) by SE Person in Charge:

  • STEP 2: REMOVE THE LOAD

  • REMOVE THE LOAD STAGE (Selected and approved [signed] by the Customer Person in Charge)

  • STEP 3: DE-ENERIZE

  • DE-ENERGIZE STAGE (Selected and approved [signed] by SE Person in Charge)

  • STEP 4: ISOLATE

  • ISOLATE Stage (Selected and approved [signed] by the SE Person in Charge)

  • STEP 5: VERIFY NO VOLTAGE * Note * All circuits are considered energized until verified.

  • VERIFY NO VOLTAGE STAGE (Selected and approved [signed] by SE Person in Charge)

  • STEP 6: GROUNDING This is not mandatory for below 600V, unless there is a potential for back feed.

  • GROUNDING STAGE (Selected and approved [signed] by Customer Person in Charge)

  • STEP 7 PROTECT CIRCUITS

  • PROTECT CIRCUITS STAGE (Selected and approved [signed] by Customer Person in Charge)

  • After even the shortest interruption of the work process (i.e., restroom, lunch, etc.), perform a visual check to
    ensure all controls are in place (locks, tags, barriers, grounding, and short-circuiting when more than 600V).

  • All 7 STEPS Complete & Signed by SE Person in Charge

SE WORK TEAM: SE EMPLOYEES AND CONTRACTORS

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about PRINT NAME to be re-energized

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized.

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized.

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized.

  • SIGN IN: I have completed steps 1-7, placed my lock on the lock-out device and will now work de-energized

  • SIGN OUT: I have finished working de-energized, removed my lock from the lock device and have been made aware the system is about to be re-energized.

  • STEP 8: ELECTRICAL TESTING

  • ELECTRICAL TESTING STAGE (Selected and approved [signed] by Customer Person in Charge)

  • STEP 9. TEMPORARY RELEASE OF LOTO/REMOVAL OF GROUNDS FOR TESTING

  • TEMPORARY RELEASE OF LOTO STAGE (Selected and approved [signed] by SE Person in Charge)

  • STEP 10. RELEASE OF LOTO/REMOVAL OF GROUNDS

  • STEP 10: RELEASE OF LOTO/REMOVAL OF GROUNDS STAGE (Selected and approved [signed} by Customer Person in Charge)

  • STEP 10: RELEASE OF LOTO/REMOVAL OF GROUNDS STAGE (Selected and approved [signed} by SE Person in Charge)

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.