• Does the work require an Energized Electrical Work Permit?

  • Was the permit approved before work began?

  • If the work does not require an Energized Electrical Work Permit were the following observed?

  • Were approach distances and arc flash boundaries determined?

  • Was arch flash PPE required?

  • What PPE category does the task fall under?

  • Are voltage rated tools required?

  • How did employee determine answers to questions above?


  • Were all "affected" and "other" employees verbally notified of the lockout?

  • Were all energy sources turned to the "off" or "safe" position?

  • Were lockout devices and locks properly attached to the energy isolation device?

  • Were warning tags indicating the authorized employee's name and the date attached to each energy isolation device?

  • Was all stored energy properly controlled? (Pneumatic & hydronic energy bled, suspended parts lowered. etc)

  • Was an attempt made to restart the equipment or otherwise ensure the effectiveness of the lockout prior to beginning the service work?

  • If a group lockout was required, did all authorized employees attach their own locks and tags to each energy isolation device?

  • Were all locks and devices properly removed after servicing?

  • Were all "affected" and "other" employees verbally notified when the lockout was completed?


  • Please fully explain all "NO" responses and note any other deficiencies that are not specifically covered by a checklist item:

  • Signature of Evaluator

  • Signature of Employee

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