Steve Johnson

Lock Out/Tag Out

Use this template to inspect lock out compliance of the job site

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Title Page

Site conducted
Conducted on
Prepared by
Employees being observed?

Observe

Do workers have locks/tags placed on appropriate lock out boxes according to their task?
What type of equipment is being locked/tagged out?
What type of energy is being isolated?
- Electrical
- Pneumatic
- Hydraulic
- Mechanical
- Potential
Are all lock out boxes clearly marked and complete?
Have all types of energy been isolated before work begins?
Has all affected people been notified?
Do workers have the proper training?

Observation/Comments

Observations during task?
Did the equipment remain secured until task was complete?
Were the locks removed in the appropriate order?
Were all affected employees notified before equipment was restarted?

Steve Johnson

Lock Out/Tag Out

Use this template to inspect lock out compliance of the job site

Use this Template

Print as PDF

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.