Lockout Tagout Checklist

• Equipment Serial #

• Site

• Conducted on

  Date

• Prepared by

General Information

• Nature of work

• Take a photo of the equipment/machinery

  Media

• Hazardous energy sources

  Select Electrical Mechanical Hydraulic Pneumatic Chemical Thermal Other

  • Electrical
  • Mechanical
  • Hydraulic
  • Pneumatic
  • Chemical
  • Thermal
  • Other

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Employees

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

Lockout/Tagout Devices

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Applying LOTO devices

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

Removing LOTO devices

• Are all tools removed and machine guards replaced?

  Yes

  No

  N/A

• Are all employees cleared off the machine?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is energy restored properly?

  Yes

  No

  N/A

Completion

• Recommendations

• Full name and Signature of the Inspector

  Sign