example_D_Blank_Clearance_Order_Form_.pdf

STATION

Clearance Date:

Clearance Time:

CLEARANCE NO. CLEARANCE COMPLETED BY

SYSTEM AND HAZARDS TO BE CLEARED

PURPOSE

CLEARANCE REQUIRED BY (NAME/TITLE)

POINT OF CONTACT

ESTIMATED TIME OF COMPLETION EST TIME TO RETURN EQUIPMENT TO SERVICE IN EMERGENCY

DATETIME

PHONE

SAFE CLEARANCE

ORDER FORM

CORPS OF ENGINEERS Page Information: 1 of 1

ER-385-1-31

PROCEDURAL STEPS AND RESPONSIBILITIES FOR PLACEMENT, REMOVAL, AND TRANSFER OF LOCKOUT/TAGOUT DEVICES

Group Clearance Sheet No(s). Issued

Clearance Holder Will Initial for Each Master Tag Sheet 1._______2._______3._______4._______5._______

Issued Lockset:___________________

AUTHORIZED BY PLACED BY

CLEARANCE ISSUED TO TIME DATE

TIMECLEARANCE RELEASED BY

CLEARANCE REMOVED BY

BY

DATE

DATETIME

ENG FORM 1927 - R, May 91 REPLACES ENG FORM 1927, Mar 71, WHICH IS OBSOLETE