Template For Specific Lockout Tag Instructions For Equipment Page 3

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ANNUAL PERIODIC INSPECTION FORM
Lockout/Tagout Periodic Inspection Form
Date of inspection: _____________________
Shop/Area: ____________________________________________________________________________
Name of Equipment or Process and Procedure Reviewed: _______________________________________
Name of Employee(s) Being Reviewed (use additional sheets if necessary):
1. ___________________________ 6.___________________________11._________________________
2. ___________________________ 7.___________________________12._________________________
3. ___________________________ 8.___________________________13._________________________
4. ___________________________ 9.___________________________14._________________________
5. _________________________ _10.___________________________15._________________________
Inspection Items – Review the Energy Control Procedure and employee responsibilities with the involved employees
and complete the following:
Yes
No
1. Are the steps in the energy control procedure being followed? (If no, provide a detailed
description of the problem below, along with a description of any corrective action taken or
planned.)
2. Do the involved employees understand their responsibilities under the procedure? (If no,
provide a detailed description of the problem and any corrective action needed below.)
3. Are there any inadequacies in any employee’s knowledge, abilities, or use of the
procedures? (If yes, provide a detailed description of the problem and any corrective action
needed below.)
4. Is the procedure adequate to provide the necessary protection? (If no, provide a detailed
description of the problem and any corrective action needed below.)
Corrective Action – Use the space provided below to describe any problems identified during
the inspection, along with a description of any corrective action needed. Appropriate action
must be taken to ensure that the deficiencies are corrected. This may involve making
changes to the procedure, providing retraining to employees, and/or taking additional steps to
ensure compliance.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
______________________________________________________________________
Person Conducting the Inspection: ______________________________________________________________
Name (Print): Signature: ____________________________________Title/Department: ____________________
(Keep a copy in auditable department records send a copy to EH&S)

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