Lockout/Tagout Periodic Inspection 403.1

Authorized Employee Information

• Observed Employee Name

• Name of Auditor

• Piece of Equipment Being Locked Out

• Select date

  Date

Lockout/Tagout Process

• Step 1- Notify others (affected employees and other personnel in area)

  Yes

  No

  N/A

• Step 2- Review Lockout Procedure

  Yes

  No

  N/A

• Step 3- Properly shutdown the machine/ Perform a machine stop<br>

  Yes

  No

  N/A

• Step 4- Isolate the equipment from the energy source

  Yes

  No

  N/A

• Step 5- Lockout and tagout the equipment by affixing locks and tags to each energy sources

  Yes

  No

  N/A

• Step 6- Release stored energy (capacitor banks, springs, compressed air, steam, hydraulics, etc)

  Yes

  No

  N/A

• Step 7- Attempt to restart/ Verification that all energy sources are isolated and at a Zero Energy State.<br>

  Yes

  No

  N/A

Lockout Removal Process

• Step 1- Check machine to ensure all tools and items have been removed

  Yes

  No

  N/A

• Step 2- Check area to confirm that all employees are safely located

  Yes

  No

  N/A

• Step 3- Verify that all guards have been reinstalled

  Yes

  No

  N/A

• Step 4- Remove lockout devices and re-energize the machine

  Yes

  No

  N/A

• Step 5- Notify affected employees that the servicing or maintenance is completed and the machine is ready for use.

  Yes

  No

  N/A

Verification

• Employee was able to conduct Lockout/Tagout process correctly and all steps were conducted sequentially

  Yes

  No

  N/A

• Employee demonstrates ability and knowledge to properly conduct lockout/tagout when necessary

  Yes

  No

  N/A

• Employee understands that he/she will be subject to periodic audits as deemed necessary by management<br>

  Yes

  No

  N/A

• Employee understands that violation of lockout/tagout policy can and will result in disciplinary action, up to and including termination

  Yes

  No

  N/A

Additional Machine Audit Items

• Is the Lockout Tagout procedure posted on the piece of equipment?

  Yes

  No

  N/A

• Is the Lockout Tagout procedure still accurate with the correct information?

  Yes

  No

  N/A

• Are all of the lockout points labeled and working correctly?

  Yes

  No

  N/A

• Is the Arc Flash Label present?

  Yes

  No

  N/A

• Observed Employee Signature

  Sign

• Auditor Signature

  Sign