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Lock Out and Tag Out Assurance Assessment
Lock Out and Tag Out Assurance Assessment
Jayaraman Venkatachalam

Lock Out and Tag Out Assurance Assessment

Lock out and Tag out daily assurance and verification to be completed using this template

Use this Template
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Free Lock Out and Tag Out Assurance Assessment Checklist

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Title Page

  • Site conducted

  • Conducted on

  • Audited by

  • Work Description

  • Isolation Performed by

  • Location:

  • Valid From

  • Permit Number

  • Is Tag provided in breaker / switch Gear Room?

  • Is Permit number mentioned in TAG?

  • Is Permit number mentioned in TAG is correct?

  • If more than one activity/Job on same isolation, then is it properly captured in the permit?

  • Is isolation done and signed by field engineer?

  • Is lock number is mentioned in isolation report?

  • Is lock number is same as in isolation report?

  • Is emergency push button latched and tagged?

  • Is Suction line isolated & chain locked provided?

Lock Out and Tag Out Assurance Assessment
Jayaraman Venkatachalam

Lock Out and Tag Out Assurance Assessment

Lock out and Tag out daily assurance and verification to be completed using this template

Use this Template
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.

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