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LOTO Energy Isolation Verification Checklist

Before servicing, document each energy source, the authorized person's isolation method, lock and tag accountability, stored-energy controls and proof of zero energy.

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How to use this worksheet

Identify the exact machine, maintenance task and affected workers.
Map electrical, pressure, mechanical, hydraulic, pneumatic, gravity and other energy sources.
Have authorized personnel follow the approved shutdown, physical isolation and personal lock/tag procedure.
Relieve or restrain stored energy and verify isolation through an appropriate safe test before work.
Follow the employer's controlled lock transfer, shift handover and return-to-service procedure when circumstances change.

Worked field example

Example — Pump repair: Isolate and lock the motor supply, depressurize the line, prevent rotor movement, and have an authorized worker verify the de-energized state before service.

SERNEM — FIELD WORKSHEET

LOTO Energy Isolation Verification Checklist

Adapt this worksheet to actual site conditions.

Equipment and responsibilities

Equipment / asset IDArea / locationDate and shiftPermit / work order referenceAuthorized isolating person

Energy isolation point register

Energy source / point	Isolation and lock method	Verification / result	Authorized person
Energy source / point 1	Isolation and lock method 1	Verification / result 1	Authorized person 1
Energy source / point 2	Isolation and lock method 2	Verification / result 2	Authorized person 2
Energy source / point 3	Isolation and lock method 3	Verification / result 3	Authorized person 3
Energy source / point 4	Isolation and lock method 4	Verification / result 4	Authorized person 4
Energy source / point 5	Isolation and lock method 5	Verification / result 5	Authorized person 5

Verification and release

Zero-energy verification method / resultStored or reaccumulating energy controlLock accountability / shift handoverControlled restoration and employee notification

This worksheet does not perform an isolation, prove a safe state, or authorize work. Follow the applicable energy-control standard and your employer's written procedure.

Frequently asked questions

Is a tag alone enough?

A tag is not automatically equivalent to a lock on a lockable isolator; verify the applicable legal criteria and supplementary protection.

When is isolation verified?

An authorized worker verifies effective isolation after applying controls and before servicing starts.

Related SERNEM resources

LOTO technical guide →Stored energy hazards →Quick risk assessment →

Technical sources

OSHA 29 CFR 1910.147 — Control of Hazardous Energy

This worksheet does not perform an isolation, prove a safe state, or authorize work. Follow the applicable energy-control standard and your employer's written procedure.