Lockout/Tagout (LOTO) Permit

A printable energy isolation permit modeled on OSHA 29 CFR 1910.147. Complete it before any service or maintenance work on energized equipment, and keep the signed copy.

LOCKOUT / TAGOUT PERMIT

OSHA 29 CFR 1910.147 · Complete before equipment service or maintenance

Date

8/26/2026

1. Job Information

Equipment / machine

Location

Task to be performed

Authorized employee

Date / time authorized

2. Personnel

Authorized employees

Performing the lockout

Affected employees

Working nearby

Supervisor

Expected return-to-service

3. Energy Source Isolation

Energy typeSource / magnitudeIsolation pointLock device ID

Electrical

Hydraulic

Pneumatic

Mechanical

Thermal

Stored / Gravity

4. Verification of Zero Energy

Method used

Try-out, voltage test, etc.

Verified by

Time verified

5. Additional LOTO Checks (check each verified)

All energy sources identifiedIsolation devices applied & lockedTags attached with name & dateStored energy dissipated / blockedEquipment tested in 'off' positionArea cleared of personnel

6. Authorization & Removal

Authorization signature (authorized employee)

Date / time

Removal signature (after equipment restored)

Date / time equipment returned to service

Each lock may be removed only by the employee who applied it. Equipment cannot be re-energized until all locks are removed and the area is verified clear.