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Lock-out-Tag-out Form

(1) An employee has requested a safety tagging permit from AKH Railway Project for work on a system or component. (2) The permit lists the employee's position and job number. (3) It provides spaces to record the reason for the permit, any special safety conditions required, details of installed and removed safety tags like tag number and location, and signatures of those involved including the permit issuer and inspector.

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39 views1 page

Lock-out-Tag-out Form

(1) An employee has requested a safety tagging permit from AKH Railway Project for work on a system or component. (2) The permit lists the employee's position and job number. (3) It provides spaces to record the reason for the permit, any special safety conditions required, details of installed and removed safety tags like tag number and location, and signatures of those involved including the permit issuer and inspector.

Uploaded by

apuesto726
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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EMPLOYER

EMPLOYER’S Awash-Kombolcha-Hara Gebaya (AKH) CONTRACTOR


REPRESENTATIVE
Railway Project
SYSTEM/COMPONENT SAFETY TAGGING
PERMIT

(1) PERMIT REQUESTED BY: (9) DATE: (10) PERMIT NUMBER: -07

(2) POSITION: (3) JOB NUMBER : 25299 (4) SHEET _1__ OF_1__

(5) REASON FOR PERMIT:

(6) SPECIAL CONDITIONS REQUIRED:

SAFETY TAGGING

INSTALLED REMOVED
TAG NO. LOCK NO. COMPONENT POSITION
(11) (7) (7) (7) DATE INITIAL DATE INITIAL
(12) (12) (15) (15)

(13) PERMIT ISSUED BY: SIGNATURE: (13) DATE:

INDIVDUALS/GROUPS/SIGNED ONTO THIS PERMIT

BOUNDARY CLEARED BY –
ENTITY NAME TIME DATE TIME DATE
VERIFIED SIGNATURE
(8) (8) (13) (13) (14) (14)
INITIALS (13) (14)

(16) PERMIT CLOSED BY: DATE:

Inspected by:

Copy to:  ESH Manager  Camp Management


 Equipment Manager  Security
 Construction Manager  Other…………..…..

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