Painters USA Lock Out / Tag Out v1.0

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Responsibility

• All persons installing a lockout device shall sign their names and the date on the tag to verify who is in charge of the lockout device and corresponding control of potentially hazardous situation.

Rules for Lockout Permits (Requires "qualified" authorization only)

• The qualified employee shall be knowledgeable of the circuit, system and energy that are being locked out.

• The energized electrical supply shall be deenergized and disconnected.

• The disconnecting means shall be locked and tagged out.

• An attempt to operate the disconnecting means shall be conducted to ensure operation is prohibited through the locked and tagged supply or system.

Lockout permit

• Action Steps (BEFORE WORK IS PERMITTTED TO START, THE AREA MUST BE INSPECTED TO ASSURE THAT THE FOLLOWING INSTRUCTIONS HAVE BEEN FOLLOWED AND COMPLETED. FOREMAN AND THE CUSTOMER/COMPANY MUST VERIFY.)

• Have all operating controls been turned off?

  Yes

  No

  N/A

• Have all breakers or disconnects mechanisms that service the equipment been turned off?

  Yes

  No

  N/A

• Has the employees's padlock been fixed to the breaker or disconnect mechanism?

  Yes

  No

  N/A

• Has the start control been tested to ensure the correct breaker or disconnect mechanism was shut off and locked out?

  Yes

  No

  N/A

• Has all residual or stored energy in pneumatic, hydraulic, spring, or other mechanisms been relieved, disconnected, and/or blocked?

  Yes

  No

  N/A

• Have all manual valves on piping that could cause a hazard been closed or locked out to ensure that the residual pressure on the line was relieved? (Note: Automatic valves should never be used for isolation purposes.)

  Yes

  No

  N/A

• Have all mechanisms under tension or pressure from mechanical means or gravity pressure been released or firmly blocked?

  Yes

  No

  N/A

• Are other permits (Hot Work, Confined Space Entry, Radiation, or other hazards) needed?

  Yes

  No

  N/A

Lockout Information

• What type of Lockout Permit will this be?

  SIMPLE

  COMPLEX

• Describe the equipment to be locked out, the names of workers involved and the means of accomplishing this safety procedure. (Provide as much detail as possible)

• Provide pictures of the lockout and equipment affected.

  Media

Managers Name (Project Manager or Safety Specialist only)

• Foreman Name

  Sign

Employee Name (With your signature below you attest that you are trained and "qualified" to perform DJQE Lockout Procedures)

• Employee Name

  Sign

• Employee Name

  Sign

• Employee Name

  Sign

• Employee Name

  Sign

• Employee Name

  Sign

• Employee Name

  Sign