LOTO Authorization Form

LOTO Authorization Form
Complete this form to request authorization for Lockout/Tagout (LOTO) procedures and ensure workplace safety compliance.
Name of Person Requesting Authorization*
First NameLast Name
Job Title*
Department*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Equipment or Machinery to be Locked Out*
Location of Equipment/Machinery*
Reason for Lockout/Tagout*
ElectricalMechanicalHydraulicPneumaticThermalChemicalOther
Date and Time of Lockout/Tagout Start*
MonthDayYear
Date
Hour MinutesAM/PM Option
Authorized Personnel Performing Lockout/Tagout (List names)*
Steps to Be Taken for Lockout/Tagout Procedure*
Supervisor/Manager Name*
First NameLast Name
Supervisor/Manager Email*
example@example.com
Signature of Requester (Draw your signature below to authorize this request)*
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Should be Empty: