Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Date of Inspection
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Name of Inspector: Corey Richards
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Department and Location:
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Machine/Equipment The Lockout procedure is being conducted on:
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Name of Equipment:
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Lockout Chart Number:
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Did the employee perform the Lockout procedure according to the chart?
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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.
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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.)
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Identify any deficiencies that need to be corrected
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