Title Page
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Conducted on
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Prepared by
Locate Work Area & Identify Equipment/Machinery
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Please be sure to speak with machine operator, the worker, about the issues
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Identify and provide details of equipment, machinery or other system components to be worked on
Identify All Energy Sources
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Select applicable energy sources
- Electrical
- Mechanical
- Potential
- Pneumatic
- Hydraulic
- Thermal
- Chemical
- Steam
- Momentum
- Gravity
- Other
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Provide details on Other type of energy source
Identify the Parts to be Locked Out or Isolated and Determine Lockout Methods
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Step 3: List the equipment/parts to be Locked Out
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Step 4: Determine Lock Out Method (ie: disconnect switches, line valves, blocks, blanks)
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What equipment/part(s) is locked out?
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All Lock Out points established?
Notify All Personnel Affected
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List all the people you have informed about the equipment being locked out.
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Provide name and company of individual(s) you have told about the locked out equipment.
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Are the individual(s) working in the immediate area?
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Does the individual notified normally use the locked out equipment?
Shut Down Equipment & Machinery
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Who shut down the Equipment/Machinery?
Perform the Task
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List person(s) responsible for performing the work
Task is Complete - Removal of Locks
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Removal of Locks: Notify all people involved in equipment use or in the vicinity that removal of the Locks is going to take place
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Pre-Equipment Start Up
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Notify all people involved in the area that re-starting the equipment is going to happen
Restore Power
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Start up successful
Return Control to Operating Personnel
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Inform Supervisor that power is restored to circuit; provide name of Supervisor
Record Date & Time Lockout Was Removed and System is Restored
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All tools are kept and area is cleaned
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Date & Time Completed
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Signature
Verification
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Verified By:
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Signed By:
