Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Procedure Summary
Procedure
Preparation
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Identify all energy sources connected to machine
- Electrical
- Mechanical
- Hydraulic
- Pneumatic
- Thermal
- Others
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Notify all affected employees
Shut Down Phase
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Turn off machine or equipment using the normal operating controls
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Ensure machine has completely stopped and is no longer operating
Isolate Energy Sources
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Electrical - Turn off main circuit breaker/disconnect switch
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Pneumatic - Close valves and bleed off residual pressure
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Mechanical - Block moving parts/mechanisms with guarding
Apply Lock-Out Devices
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Attach lockout devices as shown. Once attached, take a photo to show device applied correctly
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Each lock uniquely keyed and assigned to an individual?
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Tag in good condition, with name of person, date and reason for lockout clearly visible
Verify Isolation
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Attempt to start machine using the normal startup procedure. Ensure it cannot operate
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Return controls to "off" position after verification
Sign Off
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Add signature
Approval
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Date and time of approval
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Approver's signature
