Lockout/Tagout Audit Form

Title Page

Observation of locking and tagging out the equipment

Did the authorized team member inform all affected team members?
Did the authorized team member turn off the machine or equipment?
Did the authorized team member locate and isolate all energy control devices? (eg. switches, breakers, air valves, etc.)
Did the authorized team member apply locking or tagging devices to the appropriate energy control devices?
Did the authorized team member remove, release, or secure stored energy? (eg. capacitors, air pressure, etc.)
Did the authorized team member consider secondary energy sources during process?
Did the authorized team member try to run the machine or equipment before work or maintenance started on machine or equipment?
Did the authorized team member return all controls to the off or safe position before work or maintenance started on machine or equipment?

Before starting machine or equipment, did the authorize team member clear all affected team members from the machine, equipment, or area?
Before starting machine or equipment, did the authorize team member clear all tools and materials from area?
Did the authorized team member ensure all machine guards were in place before start up?
Did the authorized team member performing the lockout/tagout remove his or her lockout/tagout devices?
Has power been restored by the authorized team member?
Did the authorized team member turn on the machine or equipment and cycle through an operation to ensure start up was completed?
Did the authorized team member notify all affected personnel the process is complete?

Did EACH authorized team member working on the machine or equipment affix and remove their individually identified lock?
Did the lock and/or tag identify the individual?
When multiple team members lockout/tagout the same machine or equipment, was a supervisor assigned to monitor the process.
Auditor's Name and Signature