Information
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Document No.
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Lock Out Tag Out
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Job Number/Site
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Conducted on
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Prepared by
Notification
Identify the Authorized Employee. He or she will initial each step as it is completed.
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Authorized Employee
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Date
Identify Equipment and Circuits and their locations
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Panel disconnect where lockout is installed:
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Equipment and Circuits
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Authorized Employee Initials
Notify your supervisor, involved employees, and all affected employees that you are locking out specific items or equipment. Have All involved employees initial below before continuing.
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Notifcation
Employee Involved
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Name
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Authorized Employee Initials
Information
MAKE SURE ALL PROPER PPE IS BEING WORN BEFORE PROCEEDING.
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Authorized Employee Initials
Go to the disconnecting means at the equipment or panel and place it in the OFF position.
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Off
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Authorized Employee Initials
Install lock out device and tag at disconnecting means. Identify tag with the folowing:
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Your Name
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Your Name:
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Phone Number
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Phone Number:
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Date & Time
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Date & Time
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Authorized Employee Initials
Verify zero voltage at load terminals using a 3 point test method.
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All involved employees verified Zero voltage at load terminals or conductors using a 3 point test method.
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Involved employees
Initials
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Authorized Employee Initials
Perform work on equipment or circuit.
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Authorized Employee Initials
Completion
Verify all work is completed. inspect equipment for any non-essential tools or items and remove them before continuing.
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Work Complete By:
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Date
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Authorized Employee Initials
Notify All involved and affected employees that lockout devices will be removed and circuits or equipment will be re-energized. Have All involved employees initial below.
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Notification
Employee involved
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Name
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Authorized Employee Initials
MAKE SURE ALL PROPER PPE IS BEING WORN BEFORE PROCEEDING.
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Authorized Employee Initials
Remove your tag and lock out device. Place the disconnecting means in the ON position.
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On
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Authorized Employee Initials
Check equipment or circuit for proper operation.
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Authorized Employee Initials
Notify affected employees that work is completed.
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Authorized Employee Initials
