Template

Isolation of Services Permit Template

by Regan McCarthy, from the Community

This Isolation of Services Permit template helps plan and control isolations across water, steam, hydraulic, pneumatic, and electrical systems. Capture site details, affected services, residual hazards, photos, lockout status and warning signage, gas purging and testing for gas isolation, responsible persons, approvals, and final sign-off to safely restore services.

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With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
Services and Utilities Shutdown and Isolation Form
This asset management form helps plan and record the shutdown, interruption, or isolation of site services, including electrical, potable and recycled water, sea water, gas, sewerage, and fire services. Capture request and purchase order details, location and task information, and specify the item to be isolated. Document areas impacted, notification methods, and the people and teams informed. Log approvals, authorised personnel and licenses, start and completion times, and photo evidence of shutdown and restoration. Ensure required managers are notified and services are safely reconnected.
by Andrew Moar, from the Community
Downloads: 0
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Template
Gas Permit to Work
Use this Gas Permit to Work checklist to control gas disconnect and reconnect activities on site. Record property address and date, identify the engineer responsible, capture photos of warning notices and flue isolation tags, attach CP12 evidence, and confirm boiler reconnection before closing the permit. Ideal for utilities and facilities teams ensuring safe gas work and compliance.
by Rob Welsh, from the Community
Downloads: 10+
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Template
Permit to Work including Electrical Isolation
Use this Permit to Work including Electrical Isolation checklist to support safe isolation and control of work on site. The template guides permit authorities and isolating authorities through verifying competency, cross-referencing Work Control Certificates and Isolation Confirmation Certificates, identifying and labeling isolation points, and ensuring up-to-date drawings are available. It also prompts toolbox talks, hazard identification, and confirmation that prerequisite controls and supporting certificates are in place. Use it to monitor boundaries of the task, manage changes in scope, and document compliance with the site's safe system of work.
by Lisa Johnston, from the Community
Downloads: 0
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Template
Contractor Lockout Permit Template
Use this contractor lockout permit template to document LOTO steps before servicing equipment. Capture equipment details, energy sources, isolation points, and required lockout devices. Record stored energy hazards and dissipation methods, attach photos, and list personnel and authorizations. Set permit start and expiry, confirm PPE, and collect signatures to verify isolation and re-energization. Adapt the form to your site and applicable regulations.
by Regan McCarthy, from the Community
Downloads: 0
Get

Services and Utilities Shutdown and Isolation Form

This asset management form helps plan and record the shutdown, interruption, or isolation of site services, including electrical, potable and recycled water, sea water, gas, sewerage, and fire services. Capture request and purchase order details, location and task information, and specify the item to be isolated. Document areas impacted, notification methods, and the people and teams informed. Log approvals, authorised personnel and licenses, start and completion times, and photo evidence of shutdown and restoration. Ensure required managers are notified and services are safely reconnected.

by Andrew Moar, from the Community

Get

Template

Gas Permit to Work

Use this Gas Permit to Work checklist to control gas disconnect and reconnect activities on site. Record property address and date, identify the engineer responsible, capture photos of warning notices and flue isolation tags, attach CP12 evidence, and confirm boiler reconnection before closing the permit. Ideal for utilities and facilities teams ensuring safe gas work and compliance.

by Rob Welsh, from the Community

10+

Get

Template

Permit to Work including Electrical Isolation

Use this Permit to Work including Electrical Isolation checklist to support safe isolation and control of work on site. The template guides permit authorities and isolating authorities through verifying competency, cross-referencing Work Control Certificates and Isolation Confirmation Certificates, identifying and labeling isolation points, and ensuring up-to-date drawings are available. It also prompts toolbox talks, hazard identification, and confirmation that prerequisite controls and supporting certificates are in place. Use it to monitor boundaries of the task, manage changes in scope, and document compliance with the site's safe system of work.

by Lisa Johnston, from the Community

Get

Template

Contractor Lockout Permit Template

Use this contractor lockout permit template to document LOTO steps before servicing equipment. Capture equipment details, energy sources, isolation points, and required lockout devices. Record stored energy hazards and dissipation methods, attach photos, and list personnel and authorizations. Set permit start and expiry, confirm PPE, and collect signatures to verify isolation and re-energization. Adapt the form to your site and applicable regulations.

by Regan McCarthy, from the Community

Get

Isolation of Services Permit Template

About author

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Services and Utilities Shutdown and Isolation Form

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Services and Utilities Shutdown and Isolation Form

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