LOTO Machine Audit

• Document No.

• Audit Title

• Location
  Address

• Picture of Entire Operation

  Media

Item #1

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #2

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #3

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #4

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #5

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #6

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #7

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #8

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #9

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #10

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #11

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #12

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #13

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #14

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #15

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #16

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #17

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #18

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #19

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Item #20

• Type of Energy to Control

  Select Electricity Hydraulic Steam Gravity Pneumatic Other

  • Electricity
  • Hydraulic
  • Steam
  • Gravity
  • Pneumatic
  • Other

• What area does this lock-out point terminate?

• Picture of Equipment being Isolated

  Media

• Please include a picture here of the actual lock-out point (ie. circuit breaker, etc)

  Media

• Describe any special conditions that exist

Final Thoughts, Dates and Auditor

• Add any additional information/concerns relevant to the audit.

• Date and Time of the Audit

  Date

• Auditors Signature

  Sign