LOCKOUT TAGOUT ISOLATION PERMIT

Permit Number: [PERMIT-NUMBER] Date of Issue: [DATE-OF-ISSUE] Time of Issue: [TIME-OF-ISSUE] Valid Until: [DATE-EXPIRY] @ [TIME-EXPIRY]

1. JOB DETAILS

Company Name: [COMPANY-NAME] Site Location: [SITE-ADDRESS] Work Area/Zone: [WORK-AREA]

Description of Work to be Done: [DESCRIPTION-OF-WORK]

2. EQUIPMENT DETAILS

Equipment ID/Tag Number: [EQUIPMENT-ID] Equipment Name/Description: [EQUIPMENT-NAME]

Hazardous Energy Sources Identified (Tick all that apply):

• Electrical (Voltage: [VOLTAGE]V)
• Hydraulic
• Pneumatic
• Mechanical (Kinetic)
• Chemical
• Thermal (Steam/Hot Water)
• Gravity (Raised loads)
• Other: [OTHER-ENERGY]

3. AUTHORIZATION

I hereby authorize the isolation of the above equipment for the described work.

Authorized Person (Manager/Supervisor): ________________________ Signature: ________________________ Time: [AUTH-TIME]

4. ISOLATION PROCEDURE

A. Shutdown

Equipment has been shut down normally by: [SHUTDOWN-PERSON-NAME] Time: [SHUTDOWN-TIME]

B. Isolation Points

Energy Source	Isolation Point Description	Isolation Method (Switch/Valve/etc)	Isolated By	Time
[ENERGY-1]	[ISOLATION-POINT-1]	[METHOD-1]	[NAME-1]	[ISO-TIME-1]
[ENERGY-2]	[ISOLATION-POINT-2]	[METHOD-2]	[NAME-2]	[ISO-TIME-2]

C. Lockout / Tagout

Lockout Number: [LOCK-ID] Tag Number: [TAG-ID] Lock Applied By: [LOCK-APPLIER-NAME] Signature: ________________________

D. Verification (Zero Energy Check)

I have verified that all energy sources are isolated and zero energy exists.

• Attempted to start equipment (Failed to start - SAFE)
• Measured voltage at test points (0V)
• Bled pressure lines to 0 PSI
• Dissipated stored energy
• Mechanical blocks installed

Verified By: [VERIFIER-NAME] Signature: ________________________ Time: [VERIFY-TIME]

5. WORKER SIGN ON

Name	Trade/Role	Signature	Time On	Time Off
[WORKER-1]	[ROLE-1]		[TIME-ON-1]	[TIME-OFF-1]
[WORKER-2]	[ROLE-2]		[TIME-ON-2]	[TIME-OFF-2]

6. EXTENSIONS

Request for Extension: Reason for Extension: [REASON] New Expiry Time: [NEW-EXPIRY-TIME] Authorized By: ________________________ Time: [EXTENSION-TIME]

7. COMPLETION & HANDOVER

I certify that the work described in Section 1 is complete.

• All tools and equipment have been removed.
• All safety guards have been replaced.
• All workers are clear of the machinery.
• Non-essential personnel have left the area.

Work Completed By: [COMPLETER-NAME] Signature: ________________________ Time: [COMPLETE-TIME]

8. REMOVAL OF ISOLATION

I certify that I am removing the locks and tags listed in Section 4.

Locks/Tags Removed By: [REMOVER-NAME] Signature: ________________________ Time: [REMOVAL-TIME]

Authorizing Person (Sign Off): ________________________ Time: [FINAL-SIGNOFF-TIME]

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Permit Status: [ ] COMPLETE - [ ] CANCELLED

Note: This permit must be displayed at the work site at all times.