Equipment Safety Bypass Request Form
Use this form to request a temporary bypass or override of an equipment safety control and provide the operational, hazard, and approval details needed to review it.
Requester Information
Requester Full Name
*
First Name
Last Name
Job Title / Role
*
Department / Team
*
Work Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Equipment and Bypass Details
Equipment Name / Asset ID
*
Equipment Location / Site
*
Safety Device / Control to Be Bypassed
*
Bypass Type
*
Temporary Disablement
Override
Lockout Release
Alarm Suppression
Other
Requested Bypass Start Date/Time
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Requested Bypass End Date/Time
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Operational Justification and Risk Review
Reason for bypass request
*
Task or activity requiring the bypass
*
Duration needed
*
Hazards introduced by the bypass
*
Compensating controls or safeguards to be used during the bypass
*
Affected personnel, areas, or systems
Type of work
*
Maintenance
Testing
Troubleshooting
Emergency work
Other
Approval and Acknowledgment
Immediate Supervisor/Manager Name
*
Approving Authority Name or Role
*
Approval Status
*
Approved
Denied
Needs Review
Approval Comments / Conditions
Acknowledgment of Limited Scope and Duration
I understand the bypass is limited to the stated scope and duration.
Submit Request
Should be Empty: