Energy Isolation Log
Energy Isolation Procedure
Energy Isolation Documentation Upload
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Date
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Month
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Day
Year
Date
Prepared By
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First Name
Last Name
Email
*
example@example.com
Department
Location where energy isolation will occur
*
System Name & Description
*
Energy source or type of energy to be isolated
*
Isolation Technique/s Used
*
Specific Isolation Point
Method used to ensure that energy is effectively isolated
*
Has all energy been isolated?
Yes
No
Has all energy isolation been tested and verified?
Yes
No
Have all affected workers been notified?
Yes
No
Additional Information or Instruction as appropriate
Return to Service Procedure
Has all energy isolation work been completed and is equipment ready for operation?
Yes
No
Have nonessential items been removed and all equipment components intact and guards installed before energy isolation is removed?
Yes
No
Have all affected workers been notified and safely positioned before start-up?
Yes
No
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