LOCKOUT PERIODIC ASSESSMENT

• Area:

• Equipment:

• Machine NO.:

• Building Column:

• Date and Time:

  Date

• Shift:

  B

  G

  O

• Authorized Person(s) Name(s)

• Were all affected persons notified of the lockout?

  Yes

  No

  N/A

• By whom?

• Were written lockout procedures available?

  Yes

  No

  N/A

• Where were they located?

• Is the lockout procedure being followed?

  Yes

  No

  N/A

• State the elements not followed

• Is the lockout procedure posted?

  Yes

  No

  N/A

• Is the lockout procedure in diagram form?

  Yes

  No

  N/A

• Is the lockout procedure accurate/adequate?

  Yes

  No

  N/A

• Has lockout been performed by all persons involved?

  Yes

  No

  N/A

• Name all required energy isolating devices

• Can the energy isolating device be locked out?

  Yes

  No

  N/A

• Were blocks or pins necessary?

  Yes

  No

  N/A

• State deficiencies requiring countermeasures

• Did each authorized person lockout all required energy sources with their individual lock?

  Yes

  No

  N/A

• What action was taken?

• Did each authorized person verify lockout?

  Yes

  No

  N/A

• How was it verified?

• What changes were needed?

• Countermeasure to prevent recurrence

• Who made the changes?

• Date:

  Date

• All changes communicated to affected T/Ms?

  Yes

  No

  N/A

• Date:

  Date

Inspection performed by

• Name, Signature, Date and Time

  Sign

• Shift:

  B

  G

  O