Lockout Tagout Safety Assessment
Please complete this form to assess lockout tagout safety procedures.
Employee Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Area
*
Equipment/Machine Being Assessed
*
Is the lockout/tagout procedure clearly documented?
*
Yes
No
Partially
Are all energy sources identified and isolated?
*
Yes
No
Partially
Are lockout/tagout devices used properly?
*
Yes
No
Partially
Have all affected employees been trained on the procedure?
*
Yes
No
Partially
Comments or Additional Notes
*
Assessor's Signature
*
Submit
Should be Empty: