LOTO Inspection

Department

Equipment type & Serial number

Inspection Concuducted by

Date

Authorized Employee Name

Has the employee been trained in the procedure?

Does authorized employee know the location of the written procedure?

Does authorized employee have access to the procedure?

Are affected employee notified when the procedure is being used?

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?

Did authorized employee lock out all energy sources?

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

Did the authorized employee follow the lockout/tagout procedure?

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

Does the lockout/tagout procedure adequately protect employees?

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?

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

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

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?

Comments

Enter general comments about this inspection.

Inspector :

Doesthe authorized employee need to be retrained?

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