Information
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Job Name
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Job Number or PID
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Prepared by
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Conducted on
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Location
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Personnel Onsite
Employee Names
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Personnel
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Are walkways and runways adequate?
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Are Ladders properly constructed and secure?
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In housekeeping in good condition, all necessary debris cleaned up?
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Is illumination adequate?
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Are hard hats worn?
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Are all electrical tools guarded and grounded? GFCI used?
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Are first aid supplied adequate?
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Are fire hazards controlled?
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Are hoists and rigging properly installed and maintained?
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Is the proper protective equipment being worn?
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Is there adequate ventilation?
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Is the technician familiar with hazard communication information specific to this job?
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Are lock-out tag-out procedures being followed where necessary
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Technician Name
Employee Names
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Technician Name
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Equipment Locked Out
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Date Lock Out Performed
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Reason for Lock Out
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Energy Sources Involved:
- Electricity
- Hydraulic
- Pneumatic
- Gravity
- Steam
- Water
- Refrigerant
- Mechanical
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Did the Authorized Employee:
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Release, disconnect, restrain, or otherwise render safe all potentially stored hazardous energy?
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Notify affected employees of the lockout?
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Shutdown equipment in an orderly fashion using its normal operating controls?
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Isolate the equipment from all energy sources?
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Verify that the isolation of the equipment was effective by activating the start switch or other means?
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Continue to relieve or verify any potential stored energy would not re-accumulate?
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Remove all nonessential items and replace all equipment components (guards) before removing lockout devices?
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Check the work area and notify affected employees that the lockout devices were being removed and the equipment energized?
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Did all lockout devices have all employees names and each have their own lock?
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List any Deviations from procedures
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List any Corrective Actions Taken
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Photos of lockout tagout system
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Know the types, magnitude, hazards, location, and means to control energy?
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Are job safety rules being carried out?
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All of the above job items have been inspected. Those marked with "Correction Need" ("C"), have been corrected with the following EXCEPTION(s):
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Any additional comments:
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General Job Site Photos
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Inspector Signature