Template For Specific Lockout Tag Instructions For Equipment


Template for specific Lockout tag instructions for equipment – (Page 1of 2)
This template is to be filled out for the locking and tagging of machinery or equipment under the following
When the machine being serviced has the potential for stored or residual energy, or the re-
accumulation of stored energy after shut down;
When the machine has multiple energy sources;
When the isolation and locking of the machine will not completely deactivate it;
When the machine cannot be locked out;
Specific Instructions for Hazardous Machinery
Part I
Machine Serial Number:_______________________________________________________________________
Department Name: __________________________________________________________________________
Approved by: ____________________________________________ Date:______________________________
Part II
a. What types of hazardous energy may be present?
Circle all that apply.
Electrical Chemical Pneumatic Hydraulic Thermal Other: _______________________________________
b. Complete Energy Check List (second page of this form)
c. Special Locking and Tagging instructions or substitute for Lockout/Tagout:
Part III
Attach a diagram or photo identifying lock and tag locations:


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