LOCK OUT / TAG OUT (LOTO) PERMIT

Accomplish in 2 copies - Contractors to keep one copy at work area and one copy for HSE Department.

DANGER
Project Name: ___________________________
Reference No.:_______________  Electrocution
 Burns
Date: _____________________
 Fire
Work Area: _______________________  Explosion
 Pinned between objects
Specific Equipment to be Locked Out

ISSUED TO: SPECIFIC AREAS WHERE LOCK OUT / TAG

_____________________________________________________
OUT IS NEEDED:
WORK TO BE DONE:  Electrical control switches/ source
_____________________________________________________  Water lines/ valves
_____________________________________________________
______________________________________

DO NOT DO ANY WORK ON ENERGIZED

EQUIPMENT UNTIL THE FOLLOWING
PROCEDURES HAVE BEEN TAKEN AND
Requested by:
SIGNED BY THE AUTHORIZED
PERSONNEL. _________________________
Procedures Equipment Technical/ Operator

 Notify Building Administrator and Approved by:

operator to de-energize equipment. _________________________
Building Admin.
 Shut down machinery or equipment by
normal stopping procedure by the Assisted by:
operator. _________________________
Maintenance/ Electrical Personnel
 Place the Tag Out

 Electrical personnel shall affix Lock Out Acknowledgement:

device to the electrical main switch or
______________________________
breaker.
______________________________
 Authorized employee shall affix Lock
Out devices to the energy sources that
_________________________
require Lock Out other than electrical
Maintenance/ Electrical Personnel
energy source.

_________________________
Equipment Technical/ Operator

Form No.: F-IMS028b Rev 0 Dec 01 2015