Information

  • Job Name

  • Job Number or PID

  • Prepared by

  • Conducted on

  • Location
  • Personnel Onsite

  • Employee Names
  • Personnel

  • Are walkways and runways adequate?

  • Are Ladders properly constructed and secure?

  • In housekeeping in good condition, all necessary debris cleaned up?

  • Is illumination adequate?

  • Are hard hats worn?

  • Are all electrical tools guarded and grounded? GFCI used?

  • Are first aid supplied adequate?

  • Are fire hazards controlled?

  • Are hoists and rigging properly installed and maintained?

  • Is the proper protective equipment being worn?

  • Is there adequate ventilation?

  • Is the technician familiar with hazard communication information specific to this job?

  • Are lock-out tag-out procedures being followed where necessary

  • Technician Name

  • Employee Names
  • Technician Name

  • Equipment Locked Out

  • Date Lock Out Performed

  • Reason for Lock Out

  • Energy Sources Involved:

  • Did the Authorized Employee:

  • Release, disconnect, restrain, or otherwise render safe all potentially stored hazardous energy?

  • Notify affected employees of the lockout?

  • Shutdown equipment in an orderly fashion using its normal operating controls?

  • Isolate the equipment from all energy sources?

  • Verify that the isolation of the equipment was effective by activating the start switch or other means?

  • Continue to relieve or verify any potential stored energy would not re-accumulate?

  • Remove all nonessential items and replace all equipment components (guards) before removing lockout devices?

  • Check the work area and notify affected employees that the lockout devices were being removed and the equipment energized?

  • Did all lockout devices have all employees names and each have their own lock?

  • List any Deviations from procedures

  • List any Corrective Actions Taken

  • Photos of lockout tagout system

  • Know the types, magnitude, hazards, location, and means to control energy?

  • Are job safety rules being carried out?

  • All of the above job items have been inspected. Those marked with "Correction Need" ("C"), have been corrected with the following EXCEPTION(s):

  • Any additional comments:

  • General Job Site Photos

  • Inspector Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.