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LOTO Procedure
LOTO Procedure
Additional Contact(s):
Equipment Owner:
Facility / Building / Room:
Reviewed
by:
Approved by:
1. SCOPE OF WORK
Equipment
Descriptor
Isolation
Point
Isolation
Type
VoltageType
AF Energy /
Boundary
AF
PPE
Isolation
Position
Establis
hed
(Initials
)
Clear
ed
(Initia
ls)
PPE
Isolation
Position
Establis
hed
(Initials
)
Clear
ed
(Initia
ls)
Non-Electrical
#
Equipment
Descriptor
Isolation
Point
Isolation
Type
Energy
Source
Pressure /
Thermal /
Chemical
Equipment
Descriptor
Dissipation
Point
Stored
Energy Type
Magnitude
Page 1 of 3
LOTO Procedure Template Rev0.doc
9/4/13
PPE
Device
Establis
hed
(Initials
)
Cleared
(Initials)
4b:
This LOTO Procedure requires the following LOTO Sequence:
4c:
This LOTO Procedure requires a specific sequence. Follow filedocument.pdf,
attached.
5. SIGNATURES
LOTO Authorized Person:
"I agree that the scope of work described in Section 1 falls within the LOTO Safe Zone established by the
electrical electrical electrical electrical isolations in Section 2. I have witnessed the implementation of the
LOTO according to this permit and that zero energy state was properly verified. By signing here I confirm
that the LOTO has been fully established. "
____________________________________________________
Print Name
Signature
______________
Date
______________
Date
____________________________________________________
______________
Page 2 of 3
LOTO Procedure Template Rev0.doc
9/4/13
Print Name
Signature
____________________________________________________
Print Name
Signature
Date
______________
Date
6. Pictures (optional)
Page 3 of 3
LOTO Procedure Template Rev0.doc
9/4/13