• Picture of Entire Operation

Item #1

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #2

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #3

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #4

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #5

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #6

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #7

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #8

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #9

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #10

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #11

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #12

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #13

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #14

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #15

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #16

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #17

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #18

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #19

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • Describe any special conditions that exist

Item #20

  • Type of Energy to Control

  • What area does this lock-out point terminate?

  • Picture of Equipment being Isolated

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

  • 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

  • Auditors Signature

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