Lock Out Tag Out Form Form Number: 2025/TS/QA/Lo/069 Employee ID(Required)Employee Name(Required)Position Description(Required)Phone Number(Required)Department(Required)CEO Office Section(Required)EM Section(Required)Operations Section(Required)HR , ADMIN & IT Section(Required)HSE Section(Required)Finance Section(Required)TS Section(Required)COD Section(Required)LOTO card #(Required)Sr. # /year(Required)Date(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM Equipment Description (ID/Name)(Required)Scope of work(Required)Steps for shutting down, isolating and securing the isolation devices(Required)List the energy sources being isolated and the hazards associated With those energies(Required)Method(s) used to release the residual energy and/or materials(Required)Others remarks(Required)Section B: AuthorizationADD DETAILS S #(Required)Location of Lock/ Tag(Required)Lock/ Tag No.(Required)Lock/ Tag place Sign(Required)Remarks(Required) Section-C: Sign IN/OUT -Executors working on the Equipment: ADD DETAILS Sign INDate(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM Name(Required)Designation(Required)Sign OUTDate(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM Name(Required)Designation(Required) ADD DETAILS Date(Required) MM slash DD slash YYYY Added/ Deleted(Required)Location/ Equipment ID(Required)Requesting Authorized employee Name(Required)Lock/ tag no.(Required)Name(Required)Issuing Authority(Required) Section-E: Trial run/ Completion of work:ADD DETAILS Requested by(Required)Details of Lock/ Tags # removed(Required)Reason for release(Required)IsolationRemovedOn Date(Required) MM slash DD slash YYYY IsolationRemovedOn Time(Required) Hours : Minutes AM PM AM/PM IsolationRestoredOn Date(Required) MM slash DD slash YYYY IsolationRestoredOn Time(Required) Hours : Minutes AM PM AM/PM Issuing Authority(Required)Authorized employee(Required)
