Lockout Tagout Inspection Form

Environmental Health & Safety

E H & S

TEL NO: (818) 677-2401

FAX NO: (818) 677-5853

MAIL DROP: 8284

Lockout/Tagout
Periodic Inspection Form

Periodic Inspection Procedures:

Note: The inspector must be trained in Lockout / Tagout procedures and be an authorized employee as defined in the Lockout / Tagout procedures.

Identify an area and task where Lockout / Tagout procedures are being applied.

When it is safe to interrupt the workers, identify who you are and the purpose of the inspection.

1.	Print the names of the employees interviewed on the inspection form and check the appropriate box to indicate whether the employees interviewed are authorized or affect employees as defined in the Lockout / Tagout procedures.
2.	Ask the employees if they have been trained in Lockout / Tagout procedures. If the employees have not been trained stop the activities and contact Department Management.
3.	If the employees have been trained check the appropriate box and after the inspection verify when the training occurred.

Determine if energy control procedures are being followed. Use the attached checklist to record your findings. If energy control procedures are not being followed, stop the activities and contact Department Management.

Examine the Lockout / Tagout equipment being used and verify that if meets the minimum requirements of the procedure.

Print your name and sign and date the inspection form. Include the date you were trained in Lockout / Tagout procedures.

Forward the inspection form to Environmental Health and Safety at mail drop 8284.

1. EQUIPMENT OR DEVICE CONTROLLED (name, manufacturer, model, serial #, etc):

Building or Area:

Room:

Additional Information:

2. EMPLOYEE(S) INTERVIEWED:

1.	Employee Name:	Authorized?	Affected?
2.	Were Authorized Employee(s) trained?	Yes No
	If No, stop the activities and contact Department Management
	If Yes, after the inspection verify documentation is on file? Record the training date.

3. ARE ENERGY CONTROL PROCEDURES BEING FOLLOWED? (Ask employee to describe the procedure.)

1.	Are Energy Control Procedures being followed?	Yes No
	If NO, do this...
	If YES, do this...
	Employee Description of Procedure Correct?	Yes No

4. LOCKOUT AND TAGOUT DEVICES:

1.	Standardized Lock (singularly identifiable)?	Yes No
2.	Lock Out devices used? (i.e. multi- lock hasps)	Yes No
3.	If yes, are they substantial enough to prevent removal without the use of excessive force or unusual techniques?	Yes No
4.	Standard Tags used?	Yes No
5.	If yes, did the information include: employee name, date, and activity description?	Yes No

5. EMPLOYEE CONDUCTING INSPECTION:

Inspecting Employee Name:

Training Date:

Date:

6. ENVIRONMENTAL HEALTH AND SAFETY HAS REVIEWED THIS DOCUMENT AND APPROVED THE CONTROL OF HAZARDOUS ENERGY (Lockout / Tagout) PERIODIC INSPECTION.

Signature: ________________________________________

Date: ___________

Step 1: Before Beginning to Service Equipment		Yes	No	N/A
1.	Have the type and amount of energy source(s) on the equipment been identified?
2.	Have the possible dangers related to the energy source being controlled been identified?
3.	Are the steps necessary to control the energy source understood?
4.	Have all affected employees been notified when the equipment will be shut down for service?

Step 2: Shut Down Equipment		Yes	No	N/A
1.	Have the company & RSQUO's Safety Procedures been followed?
2.	Have the manufacturer & RSQUO's Instructions been referred to?

Step 3: Isolate the Machine or Equipment		Yes	No	N/A
1.	Has the main breaker or control switch been shut off?
2.	Have the valves been closed?
3.	Have process lines been disconnected?

Step 4: Attach Lock and Tag		Yes	No	N/A
1.	Have the lock and tag been attached?

Step 5: Control Stored Energy		Yes	No	N/A
1.	Has the electrical capacitance been bled?
2.	Have the pressure or hydraulic lines from the work area been vented or isolated?
3.	Have tanks been drained?
4.	Are switches or levers that could be moved into the start position blocked, clamped, or chained?
5.	Are lines containing process materials that are toxic, hot, cold, corrosive, or asphyxiating cleared?

Step 6: Verify That the Energy State is at Zero		Yes	No	N/A
1.	Have the start switches on the equipment been tested?
2.	Have the pressure gauges been checked to insure that lines are depressurized?
3.	Are blocks or cribs secure?
4.	Have electrical circuits been checked to verify that voltage is at zero energy?
5.	Are blanks, used to block feed chemicals, secure, and not leaking

Step 7: If you have answered yes (or N/A) to the above steps, then the correct procedures are being followed. If not, describe the corrective actions taken: