LOTO verification of proficiency

• Conducted on

  Date

• Prepared by

• Location
  Address

• Client / Site

• employees of the auditing company

General

• Qualified employees must complete a verification of their knowledge as part of the first lockout training process. The review of the newly qualified employee's knowledge consists of demonstrating a lockout at a actual facility in front of his/her supervisor. The supervisor will select a lockout procedure that includes all the different types of dangerous energy that the new employee can encounter. In addition, the knowledge of each qualified employee on the use of energy taxation must be reviewed annually.

• Employee

• Inspector

• Inspection date

  Date

• Equipment Indentification

Part I – Demonstration

• Employee can locate equipment-specific lockout procedure?

  Yes

  No

• Equipment locked out in accordance with procedure?

  Yes

  No

• Emergency stops released befor verfying zero energy state?

  Yes

  No

• Employee verifies zero energy state in accordance with procedure

  Yes

  No

Part II – Lock

• Employee has approved red lock?

  Yes

  No

• Permanently affixed decal on front of lock states “DANGER – LOCKED OUT”?

  Yes

  No

• Permanently affixed decal on back of lock contains name of employee?

  Yes

  No

Interpretation

• Findings

  Passed

  Failed

• Corrective Actions

• Comments

• Inspector signature

  Sign

• To the best of my knowledge and belief, I assure you that the above-mentioned employee understands the above procedure.