Electrical Lockout Checklist Form
Complete this checklist to ensure all required steps are followed during the electrical lockout/tagout process.
Equipment Name or ID
*
Location of Equipment
*
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
*
First Name
Last Name
All energy sources identified and isolated
*
Confirmed
Lock(s) and tag(s) applied to all isolation points
*
Completed
Energy isolation verified (test for zero energy)
*
Verified
All personnel notified of lockout
*
Notified
Supervisor/Authorized Person Review
First Name
Last Name
Additional Notes or Observations
Submit Checklist
Should be Empty: