LOTO Inspection

Department*

Equipment type & Serial number*

Inspection Concuducted by*

Date*

Date

Authorized Employee Name*

Has the employee been trained in the procedure?

YesNo

Does authorized employee know the location of the written procedure?

YesNo

Does authorized employee have access to the procedure?

YesNo

Are affected employee notified when the procedure is being used?

YesNo

Have affected employees been trained to recognize when the procedure is being usedand instructed not to remove lockout/tagout devices or start de-energized equipment?

YesNo

Did authorized employee lock out all energy sources?

YesNo

Did the authorized employees verify that the equipment was de-energized?

YesNo

Did the authorized employee follow the lockout/tagout procedure?

YesNo

Does the authorized employee demonstrate the proper steps for the placement,removal, and transfer of LOTO devices?

YesNo

Does the lockout/tagout procedure adequately protect employees?

YesNo

If not, list and describe the deficiencies requiring corrective action.

Before releasing the machine or equipment from LOTO, does the employee do the following:

Inspect the machine or equipment to ensure it isoperationally intact?

YesNo

Ensure that all employees are safely positioned? Flammable Liquids Stored Properly?

YesNo

Notify affected employees and all other employees in the area that the LOTO devices have been removed?

YesNo

Authorized Employee :

Note: A review can be accomplished by meeting with employees individually or in a group.

If this is a lockout procedure, Did the inspector review with authorized and affectedemployees their responsibilities under the procedure?

YesNo

Comments

Enter general comments about this inspection.

Inspector :

Doesthe authorized employee need to be retrained?

YesNo

Comments

Enter general comments about this inspection.

Lockout/Tagout (LOTO) Inspection: Authorized Employee Observed

Authorized Employee Signature & Employee Number:

Inspector Signature & Employee Number:

Lockout/Tagout(LOTO) Inspection Form