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  • Lockout Procedure Blank Form

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    Gligoric Samson
    4 views2 pages
    This document provides a form for creating an equipment-specific lockout procedure. The form includes sections for notifying employees, shutting down and blocking potential hazards of the equipment, isolating energy sources, bleeding stored energy, performing a verification test to check the effectiveness of the lockout, and returning all controls to the off position after testing.

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    a procedure

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    This document provides a form for creating an equipment-specific lockout procedure. The form includes sections for notifying employees, shutting down and blocking potential hazards of the equipment, isolating energy sources, bleeding stored energy, performing a verification test to check the effectiveness of the lockout, and returning all controls to the off position after testing.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    4 views2 pages

    Lockout Procedure Blank Form

    Uploaded by

    Gligoric Samson
    This document provides a form for creating an equipment-specific lockout procedure. The form includes sections for notifying employees, shutting down and blocking potential hazards of the equipment, isolating energy sources, bleeding stored energy, performing a verification test to check the effectiveness of the lockout, and returning all controls to the off position after testing.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Equipment Specific Lockout Procedure

    Form
    Machine or Equipment Type:
    Location: ID #

    Date Procedure Created Verified By_________________


    Date Verified__________

    1. Notify all affected employees in the area:

    2. Proper Shutdown Procedure:

    3. Blocking of Potential Mechanical Energy

    Hazard Equipment Needed Placement Safety Devices

    4. Isolation of Power Sources:

    Energy Type Isolating Device Location Procedure

    5. Bleeding of Potential Energy

    Energy Bleed Down Points Procedure

    6. Verification Test

    Lockout to Verify Controls to try: Process to verify Lockout

    -1–
    /conversion/tmp/scratch/419064732.doc
    Equipment Specific Lockout Procedure
    Form

    All controls must be returned to the “Off” position after the “Verification Test”

    -2–
    /conversion/tmp/scratch/419064732.doc

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