Section 1 Work activity details – This form must be completed in accordance with the requirements of the WHS Energy Tag and Lockout Procedure (). WO or Project No.: Isolation instructions must be developed or reviewed by an authorised isolator for the site where the isolation is being performed. Where required, the authorised isolator must also hold the appropriate qualification for the type of isolation being performed. Location of work activity: Description of work activity: Work activity details Date of isolation: Isolation to be conducted by: Isolation responsibilities De-Isolation to be conducted by: isolation not performed by Authorised Hold points requiring Authorised Isolator) Isolator involvement: Other requirements: Name: Date: Operations Y N/A Signature: Name: Date: Electrical Y N/A Signature: Authorised isolator who has prepared or reviewed Name: Date: isolation instruction. Mechanical Y N/A Signature: Name: Date: Y N/A Signature: Documentation saved at Insert file path / TRIM Number / Q-Pulse Number
Section 1 – Work activity details This form must be completed in accordance with the requirements of the WHS Energy Tag and Lockout Procedure (). Isolation instructions must be developed or reviewed by an authorised isolator for the site where the isolation is being performed. Where required, the authorised isolator must also hold the appropriate qualification for the type of isolation being performed. WO or Project No.: Work activity details Location of work activity: Description of work activity: Date of isolation: Isolation responsibilities isolation not performed by Authorised Isolator) Isolation to be conducted by: De-Isolation to be conducted by: Hold points requiring Authorised Isolator involvement: Other requirements: Authorised isolator who has prepared or reviewed isolation instruction. Operations Y N/A Name: Date: Signature: Electrical Y N/A Name: Date: Signature: Mechanical Y N/A Name: Date: Signature: Y N/A Name: Date: Signature: Documentation saved at Insert file path / TRIM Number / Q-Pulse Number