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Isolation Work Instruction Template
Corporate Safety - Template
Isolation Instruction
Doc no.
TEM-00077
Version date:
21/03/2016
Trim ID:
Doc owner:
J. Paige
Doc approver:
Manager, WHS
Rev no.
1
Page 2 of 4
The controlled version of this document is registered. All other versions are uncontrolled
Step
Isolation Point Number / Description
Isolation Point Location
Code
Isolator name
Initial
1
Access Officer / Duty Operator contacted before commencing isolation.
2
3
4
5
6
7
8
9
10
Section 3 – Test for dead / prove for dead procedure
Step
Test Point Description
Test Point Location
Isolator name
Initial
1
2
3
4
5
I confirm that all identified energy sources have been isolated, all residual energy has been dissipated, all isolation points have been locked or otherwise
secured to prevent re-energisation, and the isolations have been tested and proven to be effective.
I have demonstrated the effectiveness of the isolation to all workers who are working under the control of the isolation.
Isolation Officer
Name:
Date:
Signature:
Time:
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source: seqwater.com.au
Isolation Work Instruction Template