Title Page
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Inspector:
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Supervisor:
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Company:
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Location:
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Date:
COMPLIANCE ACHIEVED
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Is the Isolation Work Instruction available and understood by staff?
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Are "Lock Out" tags and locks and/or "Out of Service" tags in use?
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Are "Lock Out" tags and locks and/or "Out of Service" tags filled out correctly?
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Are spare “Lock Out” tags and “Out of Service” tags readily available?
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Do all employees know the tag out procedures? (Check)
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Do all employees use “Lock Out” tags and “Out of Service” tags correctly?
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Are isolation locks, scissors and tags being used for all isolations?
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Is moving plant fitted with isolator switches?
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Are all isolation devices labelled?
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Are keys removed from the isolation locks whilst personnel are working on the equipment?
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Is there a copy of the "Lockout/Tagout Quick Reference Guide" available on site?
Inspection Team
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Signature:
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Signature:
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Signature: