Electrical Shutdown Checklist Form
Complete this checklist to ensure a safe and compliant electrical shutdown process.
Shutdown Location
*
Date and Time of Shutdown
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Responsible Person
*
First Name
Last Name
Pre-Shutdown Safety Checks Completed
*
Lockout/Tagout applied
Area cleared of personnel
Warning signs posted
Other
Shutdown Confirmed
*
Yes
No
Post-Shutdown Checks
*
Equipment de-energized
Zero energy state verified
Area secured
Other
Additional Notes
Signature (Responsible Person)
*
Submit Checklist
Submit Checklist
Should be Empty: