For Tag and Lockout of Equipment Or Isolation of Electrical Circuits
(attach to completed JSA)
Site Location/Name:
Purpose for Electrical/Mechanical
Lock out:
Location of Circuit or Equipment Locked out:
For tag and lockout of equipment or isolation of electrical circuits:
Contractor personnel responsible for isolating electrical/mechanical equipment: / Completed1. Stop the equipment/ isolate area appropriately. /
2. Locate the power feed and turn it off. /
3. Attach the lock device, lock and tags. /
4. Test control of equipment to ensure it is disconnected from all power sources, check
remote start/circuit load. /
5. Other: /
Completed by:
Name: / Signature: / Date:
Worker(s) completing work on isolated electrical/mechanical equipment: / Completed
6. Attach appropriate lock and tag on multi-lock device. /
7. Test the start command/circuit load to ensure equipment is disconnected from all power sources. /
8. Perform required work. /
Upon completion of work: / Completed
9. Ensures the job site is ready for normal operations. /
10. Ensures that all trade locks have been removed. /
11. Removes lock, multi lock device and tag from the appropriate disconnect switch. (forceful removal is not permitted) /
12. Switches the power feed to the ON position. /
13. Test the equipment to ensure it is operating satisfactorily. /
Worker(s) Sign-off:
Name: / Signature: / Date:
TRANSFER OF LOCK OWNERSHIP
1. Review held between the two individuals transferring lock(s)?
(if no, then follow forceful removal of locks) / Yes
No / 2. Has Supervisor been informed and verbally approved?
(if no, then follow forceful removal of locks) / Yes
No
Name and Signature of New Lock Owner
Name: Signature: Date Transferred: Time:
Removal
Name: Signature: Date Removed: Time:
If individual who has ownership for the lock(s) cannot remove it, the forceful removal of lock requires a documented procedure
(may use back of this document)
Electrical/Mechanical Isolation Checklist October 2006