To save as PDF: use your browser's Print → Save as PDF or Print to PDF. This checklist prints as 2 pages (A4).
Verify isolation before work on or near electrical equipment.
PAGE 1 OF 2
Isolation Points
List every isolation point. Record the method, lock number, tag number, person who applied and time.
| # | Isolation Point (Location) | Method (Switch / Fuse / Link / Earth) | Lock No. | Tag No. | Applied By | Time |
|---|---|---|---|---|---|---|
| 1 | ||||||
| 2 | ||||||
| 3 | ||||||
| 4 | ||||||
| 5 | ||||||
| 6 |
Pre-Work Checks
Mark each item: P = Pass | F = Fail | N/A = Not applicable.
| # | Check | P | F | N/A |
|---|---|---|---|---|
| 1 | All affected personnel notified | |||
| 2 | Circuit/equipment identified and verified against drawings | |||
| 3 | Isolation points confirmed | |||
| 4 | All isolations applied | |||
| 5 | Personal locks applied to all points | |||
| 6 | Danger tags applied to all points | |||
| 7 | Adjacent live equipment identified and barriered |
| Test | Result | Time |
|---|---|---|
| Test on known live source (before) | Pass / Fail | |
| Test at point of work — Phase–Phase | ||
| Test at point of work — Phase–Neutral | ||
| Test at point of work — Phase–Earth | ||
| Test on known live source (after) | Pass / Fail |
Workers Under This Isolation
All workers authorised to work under this isolation must sign on below.
| # | Name | Company | Signed |
|---|---|---|---|
| 1 | |||
| 2 | |||
| 3 | |||
| 4 | |||
| 5 | |||
| 6 |
De-Isolation
Complete all items before re-energising the circuit.
| # | Check | P | F |
|---|---|---|---|
| 1 | All workers clear and accounted for | ||
| 2 | All personal locks removed | ||
| 3 | All tags removed | ||
| 4 | Circuit re-energised | ||
| 5 | Equipment tested operational | ||
| 6 | All affected personnel notified |
Declaration
I declare that all isolation points have been identified, isolated, locked and tagged. Voltage testing (prove dead) has been completed using a calibrated voltage tester proven on a known live source before and after the test. All personnel have been notified. This checklist has been completed accurately and to the best of my knowledge.