Title Page
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Client / Site
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Add location
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Select date
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Location of Lockout/Tagout Equipment
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Picture of LOTO Equipment
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Name of Equipment Being Controlled
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Location of Equipment Being Controlled
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Photo of Equipment Being Controlled
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Location of Start/Stop Control
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Picture of Start/Stop Control
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Location of Energy Control Panel
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Picture of Energy Control Panel
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Voltage Associate with Energy Control Panel
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Photos of where Lockout/Tagout Devices are to be applied.
Authorization: Only employees trained in the lockout procedures for the above Equipment and having received thorough indoctrination in the facilities lockout/tagout procedures may work in this equipment.
Purpose of Lockout
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Maintenance
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Inspection
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Cleaning
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Other
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Other Purposes for LOTO:
Energy Sources to be Considered
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Electrical
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Fuel Gasses
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Fuel Oil
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Steam
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Compressed Air
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Hydraulic
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Chemical
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Gravity
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Spring Tension
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Other
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Other Energy Sources to be Controlled
To secure: -NOTIFY ALL AFFECTED EMPLOYEES that application of lockout/tagout devices will be applied to this machine. -SHUT DOWN MACHINE USING NORMAL SHUTDOWN PROCEDURES & APPLY LOCKOUT/TAGOUT DEVICE AS FOLLOWS:
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Lockout/Tagout Procedure
Step
Test cycle the machine (Push the start button) to ensure lockout is applied correctly and/or test circuit, relieve pressure, etc. as required to ensure no energy is present.
AFTER WORK IS PERFORMED: -Clear machine or equipment of tools and materials. -Notify all affected employees and remove all tools from equipment area. -Employee(s) that applies the lockout/tagout shall remove the device(s). Start the machine/equipment as follows:
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Procedure to Start
Step
Return all lockout/tagout devices to the proper storage.
Employee Authorization
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Was this form used for employee authorization?
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Management Approval:
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Authorized Employees:
Employee
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Authorized Employee:
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Management Approval:
