Lock Off / Tag Off (LOTO)

Complete all sections. Fields marked * are required. Do not start work until this permit has been authorised and accepted.

Part A

Work Details

Permit raised by *

Job title *

Sertec employee or contractor performing LOTO *

Contractor details (if applicable)

Valid from — date *

Valid from — time *

Valid to — date *

Valid to — time *

Location of work *

Task description and location of the Lock Off Tag Off (LOTO) *

Part B

All items must be checked before work commences. Mark each item as Required (Y/N) then confirm compliance.

Safety check Required? Y N

Has the defined source of energy been locked off and tagged off?

Are all energy dissipations completed and checked prior to starting the work including drain downs?

Has the equipment under LOTO been locked off using the correct equipment provided (Locks and Labels)?

If energy cannot be isolated, has a dynamic risk assessment been completed?

Has consideration been given to other sources of energy that may have an influence on the task?

If work is carried over to next shift, have all communications on LOTO been completed?

Have other sources of energy identified been locked off and tagged off?

If work is carried over have the locks used been swapped to the next person performing the LOTO?

Have all persons involved with the LOTO been notified (including the cell Supervisor)?

On completion of work, have all persons been notified that the equipment is being switched on?

Job specific instructions or precautions

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Permit to Work Portal — For internal and contractor use only