Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
CLEARANCE REQUEST
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Was the Clearance Request/LOTO form used?
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Was the Clearance verbally requested?
CLEARANCE PREP
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Was the Clearance/LOTO produced by Red Tag Pro?
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Was the clearance/LOTO form hand written?
CLEARANCE FORM
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Was the issuing department designated?
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Was the issuing "TO" line completed?
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Was the clearance number on the form?
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Clearance number:
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Was the equipment name on the clearance form?
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Were there any special comments noted?
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Was the "Clearance Issued By" line filled out?
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Was the "Clearance Issued Date" line filled out?
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Was the "Clearance Issued Time" line filled out?
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Was the "Clearance Accepted By" line filled out?
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Was the "Clearance Accepted Date & Time" line filled out?
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Was the "Clearance Released for Corrective Action" line filled out?
CLEARANCE FORM CONTINUED
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Was the "Clearance Accepted After Corrective Action" line filled out?
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Was the "Tested/Tried/Vented/Depressurized Where" line filled out?
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Was the "Tested/Tried/Vented/Depressurized Date/Time" line filled out?
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Was the "Tested/Tried/Vented/Depressurized How" line filled out?
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Was the "Clearance Released By" line filled signed?
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Was the "Clearance Released by Date/Time" line filled out?
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Was the "SPCC Tags Released By" line filled signed?
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Was the "SPCC Tags Released By Date & Time" lines filled out?
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Was the "Tags Picked Up & Equipment Made Ready for Operations By" line filled signed?
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Was the"# of Grounds Placed" line signed?
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Was the "# of Grounds Placed By" line signed?
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Was the "# of Grounds Placed Date & Time" lines signed?
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Was the "# of Grounds Removed" line filled out?
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Was the "# of Grounds Removed by" line signed?
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Was the "# of Grounds Removed Date & Time" lines filled out?
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Was the "Device Name & Location" line filled out?
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Was the "Device #" line filled out?
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Was the "HZD" line filled out?
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Was the "Lock" line filled out?
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Was the "Tags Placed by" line filled out?
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Was the "Red" line filled out?
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Was the "Striped" line filled out?
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Was the "Test/Try by" line filled out?
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Was the Supplemental Sheet marked YES or NO?
TAGS
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Were striped tags used?
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Were Red Tags used?
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How many Striped Tags were used?
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How many Red Tags were used?
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Do the number on the "Clearance" number and "Clearance No." on the tag match?
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Was the I/A line signed?
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Was the "TAG HUNG BY" line signed?
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Was the "Equipment Name line" filled out?
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Does the "Equipment Name line" match the clearance?
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Was the "ID NO." Line filled out?
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Was the "DEPT" Line filled out?
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Does the "DEPT" line match that on the "TO" line on the clearance form?
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Does the 1st tab on the tag match that of the "Clearance No." on the tag?
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Does the 2nd tab on the tag match that of the "Clearance No." on the tag?
LOCKS
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Number of Red Equipment locks used?
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Were the lock(s) placed in the proper area(s)?
SUPPLEMENTAL SHEET
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Was a Supplement Sheet used?
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Was the Issuing Department designated?
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Was the Issuing "TO" line completed?
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Was the clearance number on the form?
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Was the equipment name on the clearance form?
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How many striped tags were used?
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How many red tags were used?
Signatures
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Select date
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Add signature
