Quarter LOTO check

• Conducted on

  Date

• Prepared by

• Location
  Address

• Client / Site

• employees of the auditing company

General

• Regular inspections shall be carried out at least quarterly and shall serve as a spot check to confirm that the lock-out procedure continues to be carried out properly. Each inspection shall include a review of the written equipment specific lockout measures, observation by a qualified operator performing the measures and identification of all corrective actions necessary to correct any deficiencies identified during the inspection. Inspections are carried out by a qualified employee who is not directly involved in the process to be evaluated. These inspections shall include all shifts and divisions.

• Employee

• Inspector

• Inspection date

  Date

• Equipment Identification

Part I – Equipment-Specific Lockout Procedure

• Employee can locate equipment-specific lockout procedure?

  Yes

  No

• Labeling of energy isolation devices match written procedure?

  Yes

  No

Part II – Lockout Demonstration

• Equipment locked out in accordance with procedure?

  Yes

  No

• Employee can demonstrate / explain verification steps?

  Yes

  No

• Employee maintains key to lock during lockout task?

  Yes

  No

Part III – Lock

• Employee has approved red lock with proper decals affixed to lock?

  Yes

  No

Part IV – Equipment Return to Service

• Machine guards / safety devices replaced?

  Yes

  No

• Employees safely positioned away from machine before start-up?

  Yes

  No

Interpretation

• Findings

  Passed

  Failed

• Corrective actions

• Comments

• To the best of my knowledge and belief, I assure you that the above-mentioned employee understands the above procedure.

• Inspector signature

  Sign