LOTO Periodic Audits

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Ask coworker the most recent time a manager and/or supervisor spoke to him/her about Lockout-Tagout

  Yes

  No

  N/A

• Have all coworkers been trained on Lockout-Tagout?

  Yes

  No

  N/A

• Is training current? Review Lockout-Tagout training records/files

  Yes

  No

  N/A

• If more than one coworker, did all coworkers have a lock on equipment?

  Yes

  No

  N/A

• Name the 5 required components of Lockout-Tagout

  Yes

  No

  N/A

• Does the coworker understand the importance of Lockout Tagout?

  Yes

  No

  N/A

• Does coworker understand when it's required to lock out a machine?

  Yes

  No

  N/A

• Did the coworker follow the 7 steps for shutdown?

  Yes

  No

  N/A

• Does the coworker understand how to isolate each energy source?

  Yes

  No

  N/A

• Does coworker understand how to properly apply device and locks?

  Yes

  No

  N/A

• Does the coworker understand group lockouts? (Have them explain)

  Yes

  No

  N/A

• Did coworker properly follow Lockout-Tagout procedure?<br> * Locate all energy source?<br> * Close and isolate all energy?<br> * Lock and test for zero energy?

  Yes

  No

  N/A

• Have the coworker explain what to do if procedure is incorrect or incomplete

  Yes

  No

  N/A

• Did the coworker follow the 5 steps for startup?

  Yes

  No

  N/A

• Is further retraining needed, or any weaknesses identified that must be addressed for this and other coworker/s?

  Yes

  No

  N/A

• Person performing audit

• Name of Coworker

• Department

• Machine or equipment audit was performed

• Add signature

  Sign

• Photo of LOTO being performed

  Media

• Note any deficiencies and/or comments

• The LOTO audit was conducted and results discussed with associate.

• Signature of authorized employee

  Sign

Has Coworker been trained on specific machine/equipment assigned.

• Signature of auditor

  Sign