Hazardous Energy Control (LOTO) Evaluation Form

Location of evaluation

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