UCPS Lockout/Tagout

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee Information

• List employees who are using lockout/tagout procedures and their last training date.

  Names

Location Information

• What is the equipment being worked on and school/facility location?

  Description

Lockout/Tagout Procedures

• What is method of LOTO being used?

  Locked

  Tagged

  Both

• Are there locks and tags for each employee?

  Yes

  No

  N/A

• What is the reason for using lockout/tagout procedures as it relates to the task at hand?

  Description

• Have proper procedures been used for lockout/tagout and shut down/restart? Explain.

  Explain

Lockout/Tagout Follow-up

• Perform a follow-up interview with each employee who participated in the lockout/tagout. Did each person exhibit knowledge and understanding of LOTO procedures?

  Explain

• Signature

  Sign