Electrical Lockout Tagout Form
Document all required steps and verification for electrical lockout/tagout procedures. Complete each section accurately to ensure safe work control.
Date and Time of Lockout
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Person Performing Lockout/Tagout
*
First Name
Last Name
Equipment ID or Tag Number
*
Equipment Location
*
Description of Equipment
*
Reason for Lockout/Tagout
*
Isolation Method Used
*
Circuit breaker locked
Disconnect switch locked
Fuse removed
Other
Lock/Tag Identifier(s)
*
Verification of Isolation (How was it confirmed the equipment is de-energized?)
*
Tested with meter
Visual confirmation
Attempted start
Other
Submit
Should be Empty: