Information

  • Client / Site

  • 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 Patterson 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

Isolation Devices & Details

Step 1 / Appendix 1

  • Type of Energy

  • 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:

Step 2 / Appendix 2

  • Type of Energy

  • 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:

Step 3 / Appendix 3

  • Type of Energy

  • 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

  • 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

  • Developed/Reviewed By (Name):

  • Periodic inspection conducted by:

  • Date of Lockout Creation / Update / Review:

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