Information

  • Site conducted

  • Procedure Title:

  • Conducted on

  • Prepared by

  • Equipment Name/Model Number:

  • Photograph of equipment:

  • Scope: Utilize this procedure for any maintenance or servicing of aforementioned equipment:
    Purpose: To protect authorized employees against unexpected activation of equipment or energy while servicing equipment.
    Authorization: The plan administrator (as defined in our company's written lockout program) is responsible for all procedural steps.
    Enforcement: Failure to properly follow lockout/tagout procedures may result in disciplinary action.

NOTIFY AFFECTED PERSONNEL THAT LOCKOUT/TAGOUT IS BEING PERFORMED

LOCATE AND ISOLATE ENERGY SOURCES

    Energy Source:
  • Type of Energy:

  • Describe hazardous nature of energy source (pressure, etc.):

  • Describe where the energy isolation point is located:

  • Photo of where the energy isolation point is located:

  • Describe how to disconnect (de-energize) this energy source:

  • Identify the device required for lockout/tagout:

  • Voltage:

  • Describe where the energy isolation point is located:

  • Photo of where the energy isolation point is located:

  • Describe how to disconnect (de-energize) this energy source:

  • Identify the device required for lockout/tagout:

VERIFY THE DE-ENERGIZATION OF ALL ENERGY SOURCES (PUSH START/STOP BUTTONS, ETC.)

PERFORM REQUIRED MAINTENANCE/SERVICE

REMOVE LOCKOUT DEVICES

  • Lockout Removal Process:
    1 - Inspect the work area to verify all tools, equipment, and materials have been removed
    2 - Verify that controls are neutral
    3 - Remove devices in reverse order
    4 - Notify employees that work is complete

RESTART EQUIPMENT

  • Developed/Reviewed By (Name):

  • Periodic inspection conducted by:

  • Date of Lockout Creation / Update / Review:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.