Template For Specific Lockout Tag Instructions For Equipment

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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
conditions:
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
MachineName:_____________________________________________________________________________
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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