Lock Out/Tag Out Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

Lock Out/Tag Out Procedures

• Authorized employee determines that LO/TO is appropriate

• JRD for the task completed and B&G appropriate personnel notified

• Time, Date and Person notified entered into the LO/TO Log Book

• Authorized employee identifies energy source to be isolated

• Affected employees notified that LO/TO to be applied

• Authorized employee securely applies lock, tag, and hasp to correct isolation device

• Authorized employee verifies voltage is not present with contact device

• Affected employee affixes personal lock and tags to hasp

• Planned work begins

Removal of Lock Out/Tag Out

• All work is complete. Affected employees notify Authorized employee

• Machine/Equipment inspected by Authorized employee

• Authorized employee verifies that all tools, spare parts, and material are removed from the work area

• Authorized employee verifies that all work is complete per NEC and Safety Standards

• Authorized employee walks the entire circuit/work area confirming that it is safe to re-energize

• Affected employee removes personal lock and tag

• Authorized employee notifies B&G that LO/TO is being removed

• All affected employees notified that LO/TO is being removed

• Authorized employee walks the entire circuit confirming that it is safe to re-energize

• Authorized employee verifies that all personnel are safely clear of area

• Authorized employee removes lock, tag and hasp

• Notify affected personnel that power will be restored

• Authorized employee re-energizes circuit

• Notify affected personnel and B&G that power has been restored.

Method of communication during Lock Out/Tag Out

• Sight/Verbal

• Job Site Radios

• Cell Phone

• Other: Please write short description of other if selected.