MEUW LOTO Periodic Inspection V1 8/6/13

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

PRE INSPECTION

• Equipment and/or Energy Control Procedure:

• Has employee received proper training as an authorized employee?

  Yes

  No

  N/A

• Review procedures. Are procedures for the equipment current?

  Yes

  No

  N/A

• Was the employee able to locate procedures?

  Yes

  No

  N/A

• Does the employee understand the procedure?

  Yes

  No

  N/A

LOTO STEPS (DE-ENERGIZE)- Did employee:

• Notify all affected employees?

  Yes

  No

  N/A

• Deactivate all energy sources in order?

  Yes

  No

  N/A

• Lock/Tag all energy sources in proper order?

  Yes

  No

  N/A

• Dissipate or restrain stored energy?

  Yes

  No

  N/A

• Use assigned Lock/Tag device?

  Yes

  No

  N/A

• Verify all energy sources have been locked out?

  Yes

  No

  N/A

LOTO STEPS (RE-ENERGIZE) - Did employee:

• Return controls to neutral position?

  Yes

  No

  N/A

• Removed tools and ensured guarding was back in place?

  Yes

  No

  N/A

• Notify affected employees prior to restoring power?

  Yes

  No

  N/A

• Energized equipment properly?

  Yes

  No

  N/A

Inspection Verification

• As the inspector do you feel based on this inspection the employee is competent with the lockout procedures and does not need to be retrained?

  Yes

  No

  N/A

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