Hazardous Energy Control Survey
Please complete this survey to assess hazardous energy control procedures and ensure compliance with safety standards.
Survey Location
*
Equipment or System Assessed
*
Person Conducting Survey
*
First Name
Last Name
Date of Survey
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Hazardous Energy Present
*
Electrical
Mechanical
Hydraulic
Pneumatic
Thermal
Chemical
Other
Are lockout/tagout (LOTO) procedures in place and being followed?
*
Yes, fully implemented
Partially implemented
Not implemented
LOTO Compliance Assessment
*
Rows
Yes
No
N/A
All energy sources identified
1
2
3
Appropriate lockout devices used
4
5
6
Warning tags attached
7
8
9
Verification of energy isolation performed
10
11
12
Authorized personnel performing procedures
13
14
15
Rate the effectiveness of current hazardous energy control measures.
*
1
2
3
4
5
Have all relevant personnel received training on hazardous energy control?
*
Yes
No
Some, but not all
Have there been any incidents or near-misses related to hazardous energy in the past 12 months?
*
Yes
No
If yes, please describe the incident(s) or near-miss(es) and corrective actions taken.
Additional Comments or Recommendations
Submit Survey
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