Lock Out / Tag Out - Equipment/Machine - duplicate

• Conducted on

  Date

• Prepared by

Locate Work Area & Identify Equipment/Machinery

• Please be sure to speak with machine operator, the worker, about the issues

  Yes

  No

• Identify and provide details of equipment, machinery or other system components to be worked on

  Safe

  At Risk

  N/A

Identify All Energy Sources

• Select applicable energy sources

  Select Electrical Mechanical Potential Pneumatic Hydraulic Thermal Chemical Steam Momentum Gravity Other

  • Electrical
  • Mechanical
  • Potential
  • Pneumatic
  • Hydraulic
  • Thermal
  • Chemical
  • Steam
  • Momentum
  • Gravity
  • Other

• Provide details on Other type of energy source

  Yes

  No

Identify the Parts to be Locked Out or Isolated and Determine Lockout Methods

• Step 3: List the equipment/parts to be Locked Out

  Yes

  No

• Step 4: Determine Lock Out Method (ie: disconnect switches, line valves, blocks, blanks)

  Yes

  No

• What equipment/part(s) is locked out?

  Yes

  No

• All Lock Out points established?

  Yes

  No

Notify All Personnel Affected

• List all the people you have informed about the equipment being locked out.

  Yes

  No

• Provide name and company of individual(s) you have told about the locked out equipment.

  Yes

  No

• Are the individual(s) working in the immediate area?

  Yes

  No

• Does the individual notified normally use the locked out equipment?

  Yes

  No

Shut Down Equipment & Machinery

• Who shut down the Equipment/Machinery?

  Yes

  No

Perform the Task

• List person(s) responsible for performing the work

  Yes

  No

Task is Complete - Removal of Locks

• Removal of Locks: Notify all people involved in equipment use or in the vicinity that removal of the Locks is going to take place

  Yes

  No

• Pre-Equipment Start Up

  Yes

  No

• Notify all people involved in the area that re-starting the equipment is going to happen

  Completed

  Not completed

Restore Power

• Start up successful

  Yes

  No

Return Control to Operating Personnel

• Inform Supervisor that power is restored to circuit; provide name of Supervisor

  Yes

  No

Record Date & Time Lockout Was Removed and System is Restored

• All tools are kept and area is cleaned

  Yes

  No

  N/A

• Date & Time Completed

  Date

• Signature

  Sign

• Verified By:

• Signed By:

  Sign