Lockout/tagout Inspection Form
Lockout/tagout Inspection Form
Lockout/tagout Inspection Form
Note to employers: Use this form to document an inspection of a written lockout or tagout procedure.
Department:
Employee name:
Yes
No
Employee name:
Yes
No
Employee name:
Yes
No
Employee name:
Yes
No
Yes
No
Yes
No
Yes
No
Have affected employees been trained to recognize when the procedure is being
used and instructed not to remove lockout/tagout devices or start de-energized
equipment?
Yes
No
Yes
No
Yes
No
Yes
No
Did the authorized employees verify that the equipment was de-energized?
Yes
No
Yes
No
Yes
No
Note: When you replace, renovate, or modify machines and equipment, ensure that
the energy-isolating devices will accept lockout devices. New equipment and
equipment renovated or modified after January 2, 1990, must be capable of being
locked out.
1.
2.
3.
4.
5.
If this is a lockout procedure, did the inspector review with all authorized
and employees their responsibilities under the procedure? Note: A review
can be accomplished by meeting with employees individually or in a group.
If this is a tagout procedure, did the inspector review with all authorized
and affected employees their responsibilities under the procedure? Note: A
review can be accomplished by meeting with employees individually or in a
group.
/var/www/apps/conversion/tmp/scratch_1/252592861.doc
Yes
No
Not applicable
Yes
No
Not applicable