Authorized Employee Lockout Audit

• Employee Name

• Department

  Single Serve

  Main Side

  Sanitation

  Warehouse

• Prepared by

• Equipment

• Date

  Date

• Locks Needed

  1

  2

  3

  4

• Locks Issued

  1

  2

  3

  4

• Type of Energy Locked Out

  Select Electrical Air Product Valve Steam Water Chemical

  • Electrical
  • Air
  • Product Valve
  • Steam
  • Water
  • Chemical

• Does the authorized employee know the location of the written lockout procedure?

  Pass

  Fail

• Does the authorized employee have access to the energy isolating devices such as the disconnects and valves to fully de-energize equipment?

  Pass

  Fail

• Were affected employees notified by the authorized employee prior to the lockout procedure being used?

  Pass

  Fail

• Did the authorized employee perform a machine stop prior to locking out equipment?

  Pass

  Fail

• Did the authorized employee follow the correct lockout procedure for the equipment being locked out?

  Pass

  Fail

• Did the authorized employee verify all energy is dissipated and is properly de-energized?

  Pass

  Fail

• Do the current energy isolating devices reflect the posted procedure? Are any changes to the procedure needed?

  Pass

  Fail

• Were alternative procedures reviewed with the authorized employee

  Compliant

  Non-Compliant

• Deficiency #1

• Deficiency #2

• Deficiency #3

• Employee Signature:

  Sign

• Supervisor Signature:

  Sign

ORM Department (Do Not Fill Out)

• Deficiencies have been corrected?

  Yes

  No

• Safety Coordinator Signature:

  Sign