Lockout/Tagout Periodic Inspection

• Document No.

• Employee being audited:

• Add location
  Address

• Conducted on

  Date

• Audit Performed by:

Pre-certification

• Employee has been trained in RPS LOTO procedures.

  Yes

  No

  N/A

• Employee can identify all stored & kinetic energy sources of equipment

  Yes

  No

  N/A

• Employee has been issued locks, keys, hasp, and tags

  Yes

  No

  N/A

• All locks are unaltered and uniform with RPS standards (Master Lock); Tags clearly identify ownership

  Yes

  No

  N/A

Lockout/Tagout Process

• Equipment & Employee performing LOTO

  Media

• Written procedure for equipment in audit

  Media

• Step 1- Identify energy sources

  Yes

  No

  N/A

• Step 2- Notify others (affected employees and other personnel in area)

  Yes

  No

  N/A

• Step 3- Shut down the equipment using normal stopping procedures for the equipment

  Yes

  No

  N/A

• Step 4- isolate the equipment from the energy source

  Yes

  No

  N/A

• Step 5- Lock out and tag the equipment by affixing locks and tags to each energy sources controlling device

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Step 7- Ensure area is clear of all personnel and verify isolation

  Yes

  No

  N/A

• Step 8- Equipment ready for servicing

  Yes

  No

  N/A

• Step. 9- Release the equipment from lockout/tagout

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

  Yes

  No

  N/A

• Employee Name & Signature

  Sign

• Auditor Name & Signature

  Sign