Title Page
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Site
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Conducted on
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Prepared by
- Lawrence Welsch
- Pat Hubbartt
- Dave Trussell
- Shane Curry
- John Lones
- Jared Ashley
- Michael Calistro
- Benson Low
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Work Order Number
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Is LOTO equipment is good condition?
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If Poor, STOP Work
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Does each Team Member have their own "RED" Lock
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If No, STOP Work
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Is LOTO posted?
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If No, STOP Work
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Where is LOTO posted?
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Is LOTO current?
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If No, STOP Work
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Does LOTO have signatures?
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If No, STOP Work
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Are LOTO devices available for the equipment?
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If No, STOP Work
LOTO - SOW
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How many LOTO Points are listed?
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Types of Energy sources
- Electrical
- Hydraulic
- Pneumatic
- Potential Energy
- Kinetic Energy
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Are photos included of LOTO points?
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If No, Take pictures of LOTO Points before continuing
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Are LOTO points marked at the source
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If No, STOP Work
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Are clear instructions posted how to perform LOTO?
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If No, STOP Work
Team Members
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How many Team Members are assigned to LOTO
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List all assigned team members names Names
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Have the Team Members been trained in LOTO?
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If Non-compliant, STOP Work
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What classification of training have the Team Members been trained for?
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Have Team Members demonstrate knowledge of LOTO, hands on performance
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If Fail, STOP Work
Verification
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Comments:
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Lead Assigned Team Member
