Lockout/tagout (Control Of Hazardous Energy) - Sample Lockout Procedures Page 4
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10Sample Lockout Procedure
Fill-in-the-Blank Template
SCOPE:
This lockout procedure is for:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Insert either of the following above:
• Company name if using a single procedure (one machine or type of machine)
or
• Specific machine or equipment that this procedure applies to, if you use multiple procedures. For
additional information, see Establish a written control program, WAC 296-803-20005, in
this chapter.
PURPOSE:
•
This procedure contains the minimum requirements to protect employees from
injury caused by the unexpected energization, start up, or release of stored
energy during service or maintenance.
•
Use this procedure to make sure the machine or equipment is stopped and
isolated from all potentially hazardous energy sources, and locked out before any
employee begins work.
AUTHORIZATION:
•
The following persons are authorized to lock out the machine or equipment using
this procedure:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
List above the names of authorized employees you want to use this procedure.
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