Title Page

  • Equipment Serial #

  • Site

  • Conducted on

  • Prepared by

General Information

  • Nature of work

  • Take a photo of the equipment/machinery

  • Hazardous energy sources

  • Enter other energy source

  • Purpose of Lockout Tagout procedure

  • Employees involved in the LOTO

Area Inspection

  • Have nonessential items (e.g., tools, spare parts) been removed from the work area?

  • Are all of the machine or equipment components operationally intact?

  • Are all employees safely positioned or have cleared the area?

  • Have all affected employees been notified that the lockout or tagout devices have been removed before the equipment started?

  • Have lockout or tagout devices been removed from the energy-isolating device by the employee who applied them?


  • Are the employees knowledgeable about the Lockout/Tagout Procedures and their responsibilities?

  • Are affected employees notified when the procedure is being used?

  • Have affected employees been trained to recognize when the procedure is being used and instructed not to remove lockout/tagout devices or start de-energized equipment?

Lockout/Tagout Devices

  • Are LOTO devices manufactured from durable materials to stand the industrial environment of their use?

  • Are they substantial enough to prevent removal without the use of excessive force?

  • Do they clearly identify the employee who installed the device?

Applying LOTO devices

  • Have all sources of power been checked before shutting down the equipment?

  • Are all effective employees notified that you are ready to start a LOTO procedure?

  • Is the equipment stopped by following its normal shutdown procedure?

  • Is the equipment isolated by turning off the energy at the main power source?

  • Are lock and appropriate lockout device (tags) applied to each energy isolating device?

  • REFERENCE: Proper lockout and tagout device attached to the power source of the isolated device.
    [This is an example of how you can use iAuditor to include best practice reference images in your templates to assist with inspections]

  • Has the power been shut off and verified?

Removing LOTO devices

  • Are all tools removed and machine guards replaced?

  • Are all employees cleared off the machine?

  • Are the LOTO devices removed by the person who applied them?

  • Are all affected employees notified that LOTO devices have been removed?

  • Is energy restored properly?


  • Recommendations

  • Full name and Signature of the Inspector

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.