Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Select date

Critical Questions

  • Does a written pre-plan exist?

  • Pre-plan number & title:

  • Is this a group or personal lock out?

  • Is the lockout log filled out for the group lockout?

  • One person,one lock and tag?

  • Are tags legible and clearly identify individual placing tag?

If NO is indicated then explain:

Authorized/qualified persons with locks placed on lock box/energy source:

Additional comments:

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.