Form library · Health and safety
Lockout tagout checklist
For authorised people recording isolation arrangements and transfer. Record work and authority, isolation points and handover and restoration. Try the form below, see every question or download a blank PDF or Word copy.
Ready to use from the form library, and every question is yours to edit. Trial from £1, cancel any time.
Try it on your phone
Try it on this phone
Fill in the lockout and isolation record on your phone now
See how the lockout and isolation record looks on your phone
Scan the code with your phone camera. It opens the real form, no sign-up needed.
Open the live example and fill it in, just as your team would on site. No sign-up needed.
See it on this phoneEvery question is editable. Add this form to your account, then change the wording, add or remove questions and options, and make it fit your own jobs.
What must be considered before maintenance isolation?
HSE guidance covers isolation of power and other supplies, prevention of unexpected restart, release of stored energy and support of parts that could move. Apply a competent, equipment-specific safe system of work.
Last updated . Facts checked by the SiteSurvey team on 6 October 2026 against HSE maintenance of work equipment and HSE maintaining electrical equipment safety.
Try the lockout and isolation record form live
Answer a few questions and watch it adapt. Your answers are not saved, and any photos you add are deleted within the hour.
This is the real form as your team would use it: questions appear as you answer, scores work themselves out and you can add photos and signatures. No sign-up needed.
Want to see one filled in? See a completed lockout and isolation record report (PDF), made by SiteSurvey from a fictional site visit.
Fill it in on a phone or tablet
Your team completes the lockout and isolation record on site in the SiteSurvey app on iPhone, iPad and Android phones and tablets. The project name and address fill in for them, it works without signal, and it syncs when the device is back online with photos kept against the question they answer.
Customers and subcontractors do not need the app: send them a link and they can fill it in from any browser.
Every question in the lockout and isolation record template
An isolation record linking equipment, energy sources, isolation points, locks, verification evidence, handovers and authorised restoration of service. 5 sections and 31 questions. Follow-up questions and guidance appear only when an answer calls for them, so the person on site never sees the ones that do not apply.
Make it your own: every question is editable
This is a starting point, not a fixed form. Once it is in your SiteSurvey account you can reword any question, add or remove questions, sections and answer options, and add your own logo, so it fits the way your team works and the jobs you do.
Details you only enter once
Add this form to a project in SiteSurvey and it fills in what the project already knows, so nobody on site retypes it and every form on the job uses the same names. Anything filled in can still be changed.
- Project: the project name
- Site or premises address: the site address, from the space or the project
- Client or organisation: the project's customer
Record details and scope
- ProjectShort answer
Filled in from the project in SiteSurvey.
Fills in from the project name - Site or premises addressShort answerFills in from the site address, from the space or the project
- Client or organisationShort answerFills in from the project's customer
- Record date*Date
- Person completing the record*Short answer
- CheckThis records an approved isolation process. It is not an isolation instruction or permit to work, and a completed checklist does not prove equipment is safe to touch.
- CheckHSE guidance covers isolation of power and other supplies, prevention of unexpected restart, release of stored energy and support of parts that could move. Apply a competent, equipment-specific safe system of work.
Work and authority
- Equipment and work boundary*Short answer
- Work order and separate permit reference*Short answer
- Approved isolation procedure and revision*Short answer
- Responsible authorised person*Short answer
- Affected people, systems and coordinationNotes
Isolation points
- Energy source and isolationRepeat for each energy source and isolation. Each one asks:
- Energy source and stored energy*Short answer
- Isolation point and identifier*Short answer
- Lock or device ID and owner*Short answer
- Applied by and date or time*Short answer
- Verification method and actual evidence under procedure*Notes
- Verification status*Choose one
- Verified under procedure
- Not verified
Handover and restoration
- Shift or personnel transfer recordNotes
Identify the responsible people, isolation references and outstanding conditions at handover. This entry records the agreed process rather than replacing it.
- Restoration status*Choose one
- Isolation remains in place
- Restoration requested
- Restored under authorised procedure
- People clear, tools removed, guards restored and affected people informed*NotesShown when “Restoration status” is “Restored under authorised procedure”
- Authorised restoration reference, person and time*Short answerShown when “Restoration status” is “Restored under authorised procedure”
Actions and review
- Are further actions required?*Choose one
- Yes
- No
- Further actionRepeat for each further action. Each one asks:Shown when “Are further actions required?” is “Yes”
- Action and evidence reference*Notes
- Person responsible*Short answer
- Target dateDate
- Action status*Choose one
- Open
- In progress
- Completed
- Completion evidence*NotesShown when “Action status” is “Completed”
- Outstanding limitations and information to pass onNotes
- Record status*Choose one
- Ready for review
- Further work needed
- Work or use stopped
- Reviewed byShort answer
- Review dateDate
- Author signature*Signature
- CheckSigning records the information entered. It does not itself certify legal compliance, remove a limitation or authorise unsafe work.
Scope and responsibility
This records an approved isolation process. It is not an isolation instruction or permit to work, and a completed checklist does not prove equipment is safe to touch.
What a useful entry looks like
Shift or personnel transfer record
Identify the responsible people, isolation references and outstanding conditions at handover. This entry records the agreed process rather than replacing it.
Outgoing and incoming authorised persons reviewed isolation schedule IS-09. Outstanding work and restoration restrictions were recorded at the handover.
Fictional example of record wording. Use the actual evidence and approved arrangements for your job; this is not a completed report or an instruction to carry out the work.
See it filled in
A completed lockout and isolation record report, made by SiteSurvey from a fictional site visit: every answer, the photos, the guidance that applied and the sign-off, ready to send as a PDF.
Lockout and Isolation Record FAQs
How should I record “Shift or personnel transfer record”?
Identify the responsible people, isolation references and outstanding conditions at handover. This entry records the agreed process rather than replacing it.
Is switching off enough?
Do not assume so. The approved procedure must address all relevant energy sources and verify isolation.
Can a lock be removed because the form is signed?
No. Lock ownership, handover and removal must follow the authorised site procedure.
How is a shift change recorded?
Use the handover field to reference the controlled transfer of responsibilities and lock arrangements.
What are the limits of this template?
This records an approved isolation process. It is not an isolation instruction or permit to work, and a completed checklist does not prove equipment is safe to touch.
Can I complete this form on site and share the record?
In the SiteSurvey app the form works offline, with signatures recorded against the questions. Share the completed record as a PDF or a link. Dates and action owners are recorded fields; this form does not send reminders or update other systems.
Related
Related templates
Templates that go with the lockout and isolation record form
A record of PPE selection, issue, condition, wearer instruction, defects and replacements, with item-level photos and acknowledgement.
A PUWER assessment record covering intended use, equipment hazards, safeguarding evidence, maintenance arrangements, competence and risk-control decisions.
A machine guarding record covering guard identity, visible condition, approved interlock checks, access risks, defects and restrictions on machine use.
Use this lockout and isolation record form with your team
Add it from the form library in one click, change any question, and every completed form becomes a branded PDF report.
Start your trial →