Title Page
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Site conducted
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Conducted on
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Conducted by:
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Department of Associate Audited:
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Machine Under LOTO Condition:
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What is the Machine or LOTO Item?
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Associate(s) Audited
LOTO Audit
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IF THE EQUIPMENT UNDER A LOTO SITUATION IS NOT LOCKED OUT - THE ASSOCIATE MUST BE REMOVED FROM THE WORKING AREA IMMEDIATELY AND THE SAFETY AND WELLNESS DEPARTMENT MUST BE MADE AWARE OF THE INFRACTION IMMEDIATELY.
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PHOTO OF EQUIPMENT/DISCONNECT LOCKED OUT:
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Was equipment powered off?
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Was the lock(s) identified with the name of the service person(s) working on it?
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Was the person being audited a Highline Associate or an Outside Contractor?
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Does each associate have their own lock on the equipment?
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Was the lock’s key on the person and secured from access by others?
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Was a lock securely in place?
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Was lockout try tested before work began?
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Comments:
Sign Off
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Name and Signature of Auditor
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Name and Signature of Audited Associate
