OECS Lockout/Tagout Machine Survey

• Site/Facility:

• Site/Facility Location:

• Conducted on:

  Date

• Prepared by:

Add Equipment

• Equipment Name / Model # / ID#

• Image(s) of Equipment / Data Plate / Existing Procedures:

  Media

• Location of Equipment:

• Is there an Existing Lockout/Tagout Procedure Created?

  Yes

  No
Add Energy Source(s):

• Type of Energy Source:

  Select Electrical Pneumatic Hydraulic Gas Mechanical Thermal Water Gravity Chemical Stored (Residual) Energy

  • Electrical
  • Pneumatic
  • Hydraulic
  • Gas
  • Mechanical
  • Thermal
  • Water
  • Gravity
  • Chemical
  • Stored (Residual) Energy

• Image of Energy Source:

  Media

• Magnitude of Energy Source:

• Location of Energy Source on Equipment:

• Describe Lockout Method:

  Select Turn the main disconnect switch to the off position and lockout Turn circuit breaker to the off position and lockout Pull the knife switch down to the off position and lockout Unplug the power cord and lockout Turn the gas cylinder to the off position and lockout Disconnect the air line and lockout Turn the ball valve to the off position and lockout Turn the gate valve to the off position and lockout Turn the air regulator to the off position and lockout Flip the air line shutoff switch to the forward position and lockout Other

  • Turn the main disconnect switch to the off position and lockout
  • Turn circuit breaker to the off position and lockout
  • Pull the knife switch down to the off position and lockout
  • Unplug the power cord and lockout
  • Turn the gas cylinder to the off position and lockout
  • Disconnect the air line and lockout
  • Turn the ball valve to the off position and lockout
  • Turn the gate valve to the off position and lockout
  • Turn the air regulator to the off position and lockout
  • Flip the air line shutoff switch to the forward position and lockout
  • Other

• Lockout Device Needed:

  Select Use a lock/tag Use a tag Use a snap on breaker lockout device and lock/tag Use a universal fuse lockout device and lock/tag Use a plug box lockout device and lock/tag Use a E-Stop cover lockout device and lock/tag Use a ball valve lockout device and lock/tag Use a air line regulator lockout device and lock/tag Use a pneumatic quick disconnect lockout device and lock/tag Use a gas cylinder lockout device and lock/tag Use a gate valve lockout device and lock/tag Use a plug valve lockout device and lock/tag Use a blocking lockout device Other

  • Use a lock/tag
  • Use a tag
  • Use a snap on breaker lockout device and lock/tag
  • Use a universal fuse lockout device and lock/tag
  • Use a plug box lockout device and lock/tag
  • Use a E-Stop cover lockout device and lock/tag
  • Use a ball valve lockout device and lock/tag
  • Use a air line regulator lockout device and lock/tag
  • Use a pneumatic quick disconnect lockout device and lock/tag
  • Use a gas cylinder lockout device and lock/tag
  • Use a gate valve lockout device and lock/tag
  • Use a plug valve lockout device and lock/tag
  • Use a blocking lockout device
  • Other

• Additional Comments and/or Recommendations:

Signature

• OECS Associate Information:

  Select