Lockout Tagout Safety Checklist
Complete this checklist to ensure all Lockout Tagout (LOTO) safety procedures have been followed before maintenance or servicing of equipment.
Equipment Name/ID
*
Location of Equipment
*
Date and Time of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Person Responsible for Lockout Tagout
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Checklist: Please indicate if each step has been completed.
*
Rows
Completed?
Notify all affected employees
1
Identify all energy sources
2
Shut down equipment
3
Isolate energy sources
4
Apply lockout/tagout devices
5
Release stored energy
6
Verify isolation of equipment
7
Perform maintenance/servicing
8
Remove lockout/tagout devices after work
9
Notify affected employees that work is complete
10
Were there any issues or hazards encountered during the process? If yes, please describe.
Additional Comments or Observations
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Signature of Responsible Person
*
Submit Checklist
Submit Checklist
Should be Empty: