David Rumsey

Lock Out Tag Out Evaluation Form

Use this form to evaluate Lock Out Tag Out authorized employees

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Use this Template

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Title Page

Audit Title
Client / Site
Conducted on
Prepared by

Did the employee notify all affected employees working in the area?
Did the employee review the Lock Out Tag Out Procedure prior to beginning Lock Out Tag Out?
Does the employee have the proper supplies to perform the Lock Out Tag Out Steps?
Did the employee follow all steps in the lockout procedure?
Did the employee dissipate any remaining energies remaining after shutdown?
Did the employee attempt to restart the machine?
After successful lockout does the employee restore the machine to normal operation?
Lock Out Tag Out Completed By: (Employee Name)
Lock Out Tag Out Evaluator:

David Rumsey

Lock Out Tag Out Evaluation Form

Use this form to evaluate Lock Out Tag Out authorized employees

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.