Title Page
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Conducted on
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Inspector(s)
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Employee Being Evaluated
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Equipment and Location where LOTO is being used
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Is Inspector an "Authorized Employee"?
SECTION II: NFPA 70E PROCEDURE
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Does the work require an Energized Electrical Work Permit?
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Was the permit approved before work began?
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If the work does not require an Energized Electrical Work Permit were the following observed?
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Were approach distances and arc flash boundaries determined?
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Was arch flash PPE required?
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What PPE category does the task fall under?
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Are voltage rated tools required?
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How did employee determine answers to questions above?
SECTION III: LOCKOUT/TAGOUT PROCEDURE (If LOTO was applied) - duplicate
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Were all "affected" and "other" employees verbally notified of the lockout?
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Were all energy sources turned to the "off" or "safe" position?
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Were lockout devices and locks properly attached to the energy isolation device?
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Were warning tags indicating the authorized employee's name and the date attached to each energy isolation device?
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Was all stored energy properly controlled? (Pneumatic & hydronic energy bled, suspended parts lowered. etc)
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Was an attempt made to restart the equipment or otherwise ensure the effectiveness of the lockout prior to beginning the service work?
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If a group lockout was required, did all authorized employees attach their own locks and tags to each energy isolation device?
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Were all locks and devices properly removed after servicing?
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Were all "affected" and "other" employees verbally notified when the lockout was completed?
SECTION IV: EVALUATION RESULTS AND SIGNATURES
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Please fully explain all "NO" responses and note any other deficiencies that are not specifically covered by a checklist item:
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Signature of Evaluator
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Signature of Employee
