Hospitals & healthcare
Lockout-tagout permit template
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Preview — Organised table
Lockout-Tagout Permit
Date: Date
No lock or tag may be removed except by the person who fitted it, after the work is done and everyone is safe.
Work
| Item | Details |
| --- | --- |
| Equipment | Equipment |
| Location | Location |
| Maintenance Description | Maintenance Description |
| Workers | Workers |
| Date and Time | Date and Time |
Energy sources
| No. | Source | Isolation Point | Lock No. | Zero Energy Verified |
| --- | --- | --- | --- | --- |
| 1 | Source 1 | Isolation Point 1 | Lock No. 1 | Zero Energy Verified 1 |
| 2 | Source 2 | Isolation Point 2 | Lock No. 2 | Zero Energy Verified 2 |
| 3 | Source 3 | Isolation Point 3 | Lock No. 3 | Zero Energy Verified 3 |
| 4 | Source 4 | Isolation Point 4 | Lock No. 4 | Zero Energy Verified 4 |
| 5 | Source 5 | Isolation Point 5 | Lock No. 5 | Zero Energy Verified 5 |
Return to service
| Item | Details |
| --- | --- |
| Work Complete | Work Complete |
| Locks Removed | Locks Removed |
| Safe Restart | Safe Restart |
| Time | Time |
Authorised Worker: Authorised Worker
Safety Officer: Safety Officer
Equipment Operator: Equipment Operator