Safety training
Control of Hazardous Energies Standard / V4 02052025
Isolation details (Clear name of the isolation and operation)
Time
Signature
Note:
Time
Signature:
One example could be: Close Valve number 5 off ☐
09:11, 14/12/2021
Jane Doe
Note:
Time:
Signature:
another example could be: Open circuit breaker 123 ☐ Apply Lockout-Tagout ☐ Test for absence of voltage ☐
09:18, 14/12/2021
Jane Doe
Time:
Signature:
Time:
Signature:
Time:
Signature:
Time:
Signature:
Time:
Signature:
Permit issued:
Do you confirm that all the above isolations have been carried out and a safe work condition has been established? ☐ Do you confirm that the following elements are fully available / implemented? ☐ • All equipment shut down by normal stopping procedures
All energy sources isolated
•
• All energy isolating equipment "locked out" with adequate lockout devices
All energy isolating equipment tagged
•
• All potentially hazardous sources or residual energy purged or dissipated
Verification of effectiveness of the isolations
•
Adequate rescue means available
•
• All personnel affected by machine/equipment shutdown notified
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