Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Date of Inspection

  • Name of Inspector: Corey Richards

  • Department and Location:

  • Machine/Equipment The Lockout procedure is being conducted on:

  • Name of Equipment:

  • Lockout Chart Number:

  • Did the employee perform the Lockout procedure according to the chart?

  • I understand how to de-energize the above mentioned Machine/Equipment. If I have any doubts or questions concerning this procedure or need any additional locks I will contact my Supervisor. In addition I certify that I understand the dangers of the above mentioned Machine/Equipment and the importance of adhering to the Kellogg Memphis Plant Lock, Tag, and Try policy at all times.

  • Does the lockout procedure performed have any deficiencies or require any modifications. (i.e. Labels missing on disconnects, procedure inaccurate, chart needs to be replaced, etc.)

  • Identify any deficiencies that need to be corrected

  • Add media

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