Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Location of evaluation
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Date and time of inspection
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List authorized employees using this procedure
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Have authorized employees been trained in the procedure
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Do authorized employees know the location of the written program
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Do authorized employees have access to the written program
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Are affected employees notified when the procedure is being used
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Have affected employees been trained to recognize when the procedure is being used and instructed not to remove tag out devices
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Can energy isolating devices be locked out
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Did the authorized employees verify that the equipment/line was de-energized
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Did the authorized employees verify a visual opening on both sides of the work
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Did the authorized employees verify that the poles/equipment were tagged
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Did the authorized employees verify the absence of voltage by testing
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Did the authorized employees verify the installation of grounds on both sides of the work
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Did the authorized employees follow the LOTO procedure
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Does the LOTO procedure adequately protect employees
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List any deficiencies that require corrective action
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Pictures of LOTO procedure
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Inspection conducted by:
