Lockout/tagout Procedure Inspection Form printable pdf download

Lockout/tagout Procedure Inspection Form

LOCKOUT/TAGOUT PROCEDURE INSPECTION FORM

Date/Time of Inspection_______________ Inspector of Procedure_________________________________

Equipment Name/Identification___________________________________________________________

Procedure Number_______________________

Revision Number / Date___________________

Authorized Employee(s) Demonstrating the Procedure________________________________________

YES

N/A

SUBJECT

COMMENTS

I. Written Equipment-Specific LOTO Procedure:

Written energy control procedure(s) available-Where?

Procedure identifies persons to be notified

Procedure identifies specific preparation steps

Procedure identifies all steps of how to shut the

equipment down

Procedure correctly identifies and quantifies all

hazardous energies to be controlled.

Procedure correctly identifies energy isolation points

and methods for all hazardous energies to be

controlled.

Procedure identifies any special LOTO devices to use

for all hazardous energies to be controlled.

Procedure identifies how to release stored energy

and prevent reaccumulation of all hazardous energies

to be controlled.

Procedure provides instructions to attempt restart of

equipment to check effectiveness of LOTO

10.

Procedure correctly identifies how to verify that all

hazardous energies are controlled.

11.

Procedure identifies how to release from LOTO.

12.

Is periodic inspection performed by authorized

employee other than the ones using procedure?

13.

If inspection reveals inadequacies are corrective

actions taken ?

Lockout/tagout Procedure Inspection Form