• Location of evaluation

  • Date and time of inspection

  • List authorized employees using this procedure

  • Have authorized employees been trained in the procedure

  • Do authorized employees know the location of the written program

  • Do authorized employees have access to the written program

  • Are affected employees notified when the procedure is being used

  • Have affected employees been trained to recognize when the procedure is being used and instructed not to remove tag out devices

  • Can energy isolating devices be locked out

  • Did the authorized employees verify that the equipment/line was de-energized

  • Did the authorized employees verify a visual opening on both sides of the work

  • Did the authorized employees verify that the poles/equipment were tagged

  • Did the authorized employees verify the absence of voltage by testing

  • Did the authorized employees verify the installation of grounds on both sides of the work

  • Did the authorized employees follow the LOTO procedure

  • Does the LOTO procedure adequately protect employees

  • List any deficiencies that require corrective action

  • Pictures of LOTO procedure

  • Inspection conducted by:

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