Information

  • Client / Site

  • Conducted on

  • Prepared by

  • Equipment Name/Model Number:

  • Scope: Utilize this procedure for any maintenance or servicing of aforementioned equipment:
    Purpose: To protect authorized employees against unexpected activation of equipment or energy while servicing equipment.
    Authorization: The plan administrator (as defined in Patterson written lockout program) is responsible for all procedural steps.
    Enforcement: Failure to properly follow lockout/tagout procedures may result in disciplinary action.

Notify affected personnel that Lockout/Tagout is Being Performed

Isolation Devices & Details

Step 1 / Appendix 1

  • Type of Energy

  • Describe where the energy isolation point is located

  • Describe how to disconnect (de-energize) this energy source

  • Identify the device required for lockout/tagout

Step 2 / Appendix 2

  • Type of Energy

  • Describe where the energy isolation point is located

  • Describe how to disconnect (de-energize) this energy source

  • Identify the device required for lockout/tagout

Step 3 / Appendix 3

  • Type of Energy

  • Describe where the energy isolation point is located

  • Describe how to disconnect (de-energize) this energy source

  • Identify the device required for lockout/tagout

  • Photos of the Steps / Appendix above in order

Verify the De-energization of all energy sources

  • Lockout Removal Process:
    1 - Inspect the work area to verify all tools, equipment, and materials have been removed 2 - Verify that controls are neutral 3 - Remove devices in reverse order 4 - Notify employees that work is complete

  • Developed/Reviewed By (Name):

  • Date of Lockout Creation / Update:

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.