Title Page

  • Department

  • Type of Lock Out:

  • Date:

  • Lock Out Done by:

  • Sinagture

  • Process/ Task/ Machine:

  • undefined


  • 1. Is the Lock out procedure available and understood by staff?

  • 1.1. Verify by asking questions

  • 2. Are "Lock Out" tags and locks and/or "Out of Service" tags in use?

  • 3. Are "Lock Out" tags and locks and/or "Out of Service" tags filled out correctly?

  • 4. Are spare “Lock Out” tags and “Out of Service” tags readily available?

  • 5. Do all employees use “Lock Out” tags and “Out of Service” tags correctly?

  • 6. Are lock out locks, scissors and tags being used for all isolations?

  • 7. Are all isolation devices labelled?

  • 8. Are keys removed from the lock out locks whilst personnel are working on the equipment?

  • 9. Is there a copy of the "Lockout/Tagout Quick Reference Guide" available on site? ( One Plan Lesson)

  • 10. Are all personnel and operators who is required to lock out, trained?

  • 11. Are all machinery or equipment capable of movement, required to be de-energized or disengaged and locked-out during <br> cleaning, servicing, adjusting or setting up operations, whenever required? (CAN IT BE LOCKED OUT? place to attach locks,etc.)

  • 12. Does the lockout procedure require that stored energy (mechanical, hydraulic, air, etc.) be released or blocked before equipment <br> is locked-out for repairs?

  • 13. Are employees required to keep personal control of their key(s) while they have safety locks in use?

  • 13.1 Is a register available and up to date?

  • 14. Is it required that only the employee exposed to the hazard, place or remove the safety lock?

  • 15. Is it required that employees check the safety of the lock-out by attempting a startup after making sure no one is exposed?

  • 16. Are employees instructed to always push the E - stop button immediately after checking the safety of the lock-out?

  • 17. Are there a means provided to identify any or all employees who are working on locked-out equipment by their <br> locks or accompanying tags?

  • 18. Are a sufficient number of accident preventive signs or tags and safety padlocks provided for any reasonably <br> foreseeable repair emergency?

  • 19. When machine operations, configuration or size requires the operator to leave his or her control station to install <br> tools or perform other operations, and that part of the machine could move if accidentally activated. Is such <br> element required to be separately locked or blocked out?

  • 20. In the event that equipment or lines cannot be shut down, locked-out and tagged, is a safe job the procedure <br> established and rigidly followed?

  • 21. Are all staff wearing correct PPE?


  • Action Required:

  • By Whom:

  • Target Date:

  • Auditee

  • Auditor

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.