Tagout Authorization Form (TAF)

/ Form 000.653.F0278
Tagout Authorization Form (TAF)
TAF No.: / Work Package No(s).:
(if applicable)
Project: / Facility/Location:
(title/ number) / (area/bldg.)
Purpose of the Tagout (summarize work to be performed and reason for the tagout):
Special Instructions for Installing/Removing Tags (if applicable):

Personnel Hazards Involved

(a. mandatory for danger tags; b. identify or describe ALL hazards; c. list details in the comment section as applicable, such as voltages and pressures):
Electrical / Chemical / Other/Comments:
Pneumatic / Thermal
Moving/Rotating Equip. / Stored or Residual
Mechanical / Hydraulic
Radiation / Compressed Gases
Instructions to Enter on Caution Tags (as they are to appear on the tag):
Surveillance Record (surveillances must be conducted QUARTERLY):
Initial and Date / Initial and Date / Initial and Date / Initial and Date / Initial and Date
Form Instructions:
Do not use arrows or ditto marks ("). (Signing across blocks is acceptable.)
Signature and/or initials will be acceptable.
Hold completed form for 6 months following the removal of the last tag; then discard.
Tags are grouped on this form only for convenience and installed and removed individually unless otherwise stated in the Special Instructions block.
A technical review must be performed to ensure all hazards; isolation points or boundaries; impacts to facilities, systems, and/or processes are identified and that the appropriate tag is used.
Copyright © 2009, P2S. All Rights Reserved.
Form Date: 01May2009 / Page 1 of 2 / Health, Safety, and Environmental
/ Form 000.653.F0278
Tagout Authorization Form (TAF)
TAF No.: / /

INITIAL THE BOXES AND SIGN IN THE SPACE PROVIDED BELOW

Tagout Information /

Authorization

Installation

Removal

Tag No. / Tag Type
(select one) / Component Tagged/Location (1) / Position /
Condition / Lock? / Technical
Review
By/Date / Installation
Approval
By/Date / Installed
By/Date / Verified
By/Date (2) / Safe Cond.
Check By/
Date/Time / Removal
Approval
By/Date / Restore to
Position/
Condition / Removed
By/Date
DDNO
Caution
Danger (3) / Yes
No
DDNO
Caution
Danger (3) / Yes
No
DDNO
Caution
Danger (3) / Yes
No
DDNO
Caution
Danger (3) / Yes
No
DDNO
Caution
Danger (3) / Yes
No
DDNO
Caution
Danger (3) / Yes
No
DDNO
Caution
Danger (3) / Yes
No
Note: When initialing above, provide the following information: (if space is limited, attach additional pages)
Name (print) / Signature / Initial / Name (print) / Signature / Initial
DO NOT USE ARROWS OR DITTO (") MARKS

(1) Enter a clear, specific description.

(2) This indicates that he or she personally checked that the lockout/tagout device is installed on the correct item in the correct position.

(3) Authorized Worker Danger Tag: Use only as allowed by the procedure.

Note: This form is referenced in Practice 000.653.3315.