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