LOTO SUPERVISOR FORM

A. Requesting a LOTO (1-5) Page ___ of ___

1 Requestor Name 2 Requested LOTO Date 3 Equipment or System being LOTOed & ID#

4 Reason for LOTO 5 Work Order #

B. Originating a LOTO (6-12)

6 LOTO Number

7 Preparation Steps Taken (list steps to shutdown the equipment OR reference the 8 Re-Energization Steps Required
Operating Procedure)

C. Placement of LOTO Devices and Verification (15-19) E. Closing the LOTO or I. Testing (29-31)
9 10 Energy Isolation Device ID & 11 12 Device 15 Lock & Tag Hung 16 Verification 17 Verification 29 Removal 30 Device 31 LOTO Removed:
Lock / Tag # Location of Lock & Tag Energy Position By: Initials / Date Requirement Completed: Initials Authorized By: Position Initials / Date / Time
(Breakers, Valves, Switches, etc.) Type* After (multimeter, open / Date After
and LOTO bleed valve, attempt LOTO
Magni- Hung to start) Removed
tude (open, (open,
closed) closed)

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*Ch=Chemical/El=Electrical/Ga=Gas/Hy=Hydraulic/Pn=Pneumatic/ 18 LOTO Supervisor Name/ Signature: Signature here indicates the LOTO is closed
SW=Steam,Water/Th=Thermal ______________________ / ______________________ 45 LOTO Supervisor Name/Signature
19 Date/Time: __________ / _________ _________________/ ________________
 AUTHORIZED EMPLOYEE (AE) FORM
6 LOTO Number Page ___ of ___
D. Authorized Employee LOTO (20-26) E. Closing the LOTO or I. Testing (27-28)
20 Pre-Job 21 AE Name 22 Work to be Done 23 LOTO Walkdown 24 Lock 27 Lock 28 AE Name
Briefing Added Removed

LS/AE Initials Print / Signature Acc/Dec Initial / Date Date / Time Date / Time Print / Signature
Exmpl. MS / JS John Smith / John Smith Repair motor A JS / 7/3 7/3 / 14: 7/3 / 20: John Smith / John Smith
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25 LOTO Supervisor Name / Signature: ______________________ / ________________________ 26 Date / Time: ______________ / ______________
 LOTO INDEX
C. Placement of LOTO Devices and Verification (6,3, 13-14) E. Closing the LOTO (32-33)
(6) (3) (13) (14) (32) (33)
LOTO Supervisor LOTO Supervisor
LOTO # System/Equipment Name / Signature Date Name / Signature Date

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 DEVICE UNDER OPERATION/TEST FORM
I. Device Under Test
34 Requestor Name 35 Test Date 46 Equipment or System being Tested

36 Reason for Test 6 LOTO Number

37 38 Energy Isolation Device ID & Location 39 Position of Device

Lock / Tag # of Lock & Tag While Being
Operated/Tested

/ 41 Test Start Time:

/ 42 Locks/Tags Need to be Rehung? (Y/N):

/ 43 Test End Time:

/ Signature here indicates that testing is complete

/ 44 LOTO Supervisor Name / Signature: _____________________ / _______________________

/
Signature here indicates approval to remove above locks and tags for testing.

40 LOTO Supervisor Name / Signature: _____________________ / _______________________