FORMAT STGYM. SSOMA.ET.077.

F01-IN
OCCUPATIONAL HEALTH SAFETY AND
Revisión: 00
ENVIRONMENT DEPARTMENT
AUTHORISATION TO REMOVE LOCKOUT – TAGOUT Página 1 de 1

COMPLETE THIS QUESTIONNAIRE BEFORE REMOVING LOCKOUT LOCKS / LOCKOUT TAGS

Chief of the Area:

Type of work: Planned Routine Emergency breakdown

Owner of the lockout lock / lockout tag to be removed:

All areas have been investigated in order to ensure that the person is not in this location:

Inside the Corporate

Crib room Polyclinic Room
machine Office

Lockout lock code:

Location of the lockout lock:

Reason to place the lockout lock /

lockout tag:

Reason to remove the lockout lock /

lockout tag:

Is the insulation complete? Yes No

Before removing the lockout lock / lockout tag,

Yes No
is the area de-energised:

Who will re-energise the area?

Is it safe to operate the equipment /

Yes No
workplace?

Is it registered in the daily log? Yes No

Signature of the Project Manager:

Date: Time:

Elaborado por: José Sánchez Velásquez Fecha de emisión: 27/11/14

Revisado por: Omar Santiago Zevallos Fecha de impresión: 03/08/2018
Traducido por: Sadot Marquez Chavez Frecuencia de revisión: 24 meses
Aprobado por: Julio Martínez La Torre Página: 1 of 1
COPIA NO CONTROLADA. El documento impreso probablemente no es una emisión vigente.
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