Scribd
Upload
92 views

Electrical Isolation Certificate: Company Forms and Check Lists

This document is an electrical isolation certificate template used for documenting electrical work done on vessels. The template includes fields for vessel name, date, time, certificate number, description of drive/equipment being worked on, work to be done, person doing the work, isolation method, authorizations from supervisors, isolating and reconnecting of power supplies, completion and clearance of work, and signatures. The certificate is required to be filled out any time electrical work is done on a vessel and kept on file for three years.

Uploaded by

opytnymoryak
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
92 views

Electrical Isolation Certificate: Company Forms and Check Lists

This document is an electrical isolation certificate template used for documenting electrical work done on vessels. The template includes fields for vessel name, date, time, certificate number, description of drive/equipment being worked on, work to be done, person doing the work, isolation method, authorizations from supervisors, isolating and reconnecting of power supplies, completion and clearance of work, and signatures. The certificate is required to be filled out any time electrical work is done on a vessel and kept on file for three years.

Uploaded by

opytnymoryak
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Date : 03.04.

01
Rev.No : 1
Prep. : MGV
App.
: CAP
Section : 02
Page : 1 of 1

ELECTRICAL ISOLATION
CERTIFICATE
Company Forms and Check Lists
Vessel Name:

Date:

Time:

Certificate No:

Drive No and/or equipment description: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


.........................................................................................................
.........................................................................................................
Work to be done: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........................................................................................................
.........................................................................................................
Work to be done by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Method of isolation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................................................
Authorized by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Supply isolated by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EIC received by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Work completed by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Work cleared by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................................................................................................
Supply Reconnection
Authorized by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Supply reconnected by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Note: The person engaged on the above work must hold this certificate until the job is completed when he will sign it,
have it cleared by his immediate supervisor and return it to the issuing authority.
Master

Person in charge of work

Signature

Signature

INSTRUCTIONS :
To be filled in every time the vessel is engaged in electrical work. Certificate is to be filed in Safety Officer's file Section 5 and kept
for a period of three years .
C:\FORMS\02_0006.PDF

MT LADON

You might also like