Lockout Tagout Permit Form
Complete this form to initiate and authorize lockout/tagout procedures for maintenance or servicing work. Ensure all safety and permit requirements are addressed.
Requester Full Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Location
*
Equipment or Machine Identification
*
Description of Maintenance or Service Task
*
Date and Time of Planned Work
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Lockout/Tagout Category or Primary Energy Source
*
Please Select
Electrical
Mechanical
Hydraulic
Pneumatic
Thermal
Chemical
Other
Isolation Points or Energy Sources to be Controlled
*
Verification of Zero-Energy State Completed
*
Yes, zero-energy state verified
No, not yet verified
Required Protective Equipment or Tools
*
Lockout devices
Tagout devices
Gloves
Safety glasses
Face shield
Insulated tools
Other
Authorization/Approval for Permit Release
*
Submit Permit Request
Submit Permit Request
Should be Empty: