Form Number: PIC-SH-19-1 Integrated Management System

FSSC 22000, ISO 14001 & OSHAS 18001 Standards

Effectivity Date: 30-Jan-18 Authorization to Remove

Page Number: 1 of 1 Locks & Tags Form

Date: Time:
Lock Number: Tag/Lock holder Name:
Equipment Involved: Team Leader completing form:
Manager:
Actions
1. Determine if Lock / Tag holder is still on Inspect clock card.
premises Findings/Action:

Manager/Supervisor Signature:
___________________________
2. Attempted to contact Lock / Tag holder at Findings/Actions:
Home:

Time: Manager/Supervisor Signature:

___________________________
3. Contact Production Manager/Maintenance Findings/Actions:

Time: Manager/Supervisor Signature:

___________________________
4. Production Manager and Maintenance Findings/Actions:
Manager conduct a safety assessment of
plant/equipment.

Production Manager/Maintenance Signature:

___________________________________
___________________________________ Manager/Supervisor Signature:
___________________________
Production Manager/Factory Manager Witness Name:
authorized removal Lock & Tag at:
Time:____________ Date:_____________ Witness Signature:

Production Manager/Maintenance Signature: Witness Name:

Witness Signature:
___________________________________
Items removed (Please tick)
□ Personal Safety Lock Removed □ Danger Tag removed
□ Barrier Tape/Temporary Barricades     □  Other (specify)
   

Another person’s Personal Lock Out Tags and Personal Safety Locks can only be removed by the
production Manager/Maintenance Manager, after all steps on this form have been carried out to
locate or contact the original person who applied the Lock Out / Tag.