Isolation Work Instruction Template - Free Download
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Section 1 – Work activity details
This form must be completed in accordance with the requirements of the WHS Energy Tag and Lockout Procedure (PRO-00014).
Isolation instructions must be developed or reviewed by an authorised isolator for the site where the isolation is being performed.
Where required, the authorised isolator must also hold the appropriate qualification for the type of isolation being performed.
Work Order No.
Work activity details
Location of work activity:
Description of work activity:
Date of isolation:
prepared or reviewed by
Operations Y N/A
Electrical Y N/A
Mechanical Y N/A
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Section 2 – Isolation procedure
Low Voltage Isolation
High Voltage Isolation
Operations Work Instruction
Valve Locked Open
Valve Locked Closed
Tag Only (isolation point
cannot be secured with a lock)
Spool Removed (Blank
Note: All HV Isolations require a High Voltage Access Permit (FRM-00439) and a High Voltage Switching Form (FRM-00438).
Devices not capable of being locked should, as far as reasonably practicable, be secured with a shroud, valve cover, chain, pin or other suitable means, or by the removal of the handle
or operating mechanism. As a minimum, an isolation tag must be affixed to any isolation point not able to be secured with a red isolation lock.