Title Page

  • Inspector:

  • Supervisor:

  • Company:

  • Location:
  • Date:

COMPLIANCE ACHIEVED

  • Is the Isolation Work Instruction available and understood by staff?

  • Are "Lock Out" tags and locks and/or "Out of Service" tags in use?

  • Are "Lock Out" tags and locks and/or "Out of Service" tags filled out correctly?

  • Are spare “Lock Out” tags and “Out of Service” tags readily available?

  • Do all employees know the tag out procedures? (Check)

  • Do all employees use “Lock Out” tags and “Out of Service” tags correctly?

  • Are isolation locks, scissors and tags being used for all isolations?

  • Is moving plant fitted with isolator switches?

  • Are all isolation devices labelled?

  • Are keys removed from the isolation locks whilst personnel are working on the equipment?

  • Is there a copy of the "Lockout/Tagout Quick Reference Guide" available on site?

Inspection Team

  • Signature:

  • Signature:

  • Signature:

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