• Document No.

  • Site

  • Conducted on

  • Prepared by

  • Personnel

Review LOTO hardware

  • Do LOTO devices meet the following criteria? 1910.147(c)(5)(ii)<br> 1. Singularly identified<br> 2. Used only on LOTO<br> 3. Durable<br> 4. Capable of withstanding the environment<br> 5. Capable of becoming wet without deterioration<br> 6. Capable of withstanding acidic or basic environments where acids or bases are stored<br> 7. Standardized - Same color, design, shape, etc. Must meet one criteria<br> 8. Substantial/Heavy Duty<br> 9. Identifiable<br> 10. Provide a warning to employees

  • Are they being maintained?

  • Adequate supply on hand?

  • Properly stored or located?

  • Used only for LOTO?

  • Do authorized employees have a good knowledge of use and location of devices?


  • Equipment inspected:

  • Equipment
  • Equipment name

  • Equipment Location

  • Is a written machine specific isolation (LOTO) procedure available and posted?

  • Does the procedure identify all energy sources?

  • What types of energy does this equipment have?

Procedure Audit

  • Employee observed:

  • Did the employee notify affected employees that the machine was being shutdown and locked out?

  • Did the employee shutdown the equipment properly?

  • Did the employee isolate all energy sources?

  • Did the employee apply locks and / or tags to all energy sources?

  • Did the employee release any stored energy, if applicable?

  • Did the employee verify that the equipment was locked out?

  • Did the employee follow correct release from lockout procedures?

  • Is the identification on the LOTO device correct?

  • Auditor signature

Recommendations / Corrective Actions :

  • Are there additional recommendations / corrective actions?

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