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Lockout/Tagout (Loto) Checklist: 1. Scope of Work

This document is a lockout/tagout checklist that contains sections for equipment details, energy isolation points, stored energy dissipation, lockout sequence, and signatures. The checklist is used to establish and clear lockouts for equipment during maintenance to ensure worker safety.

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Putri Una
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1K views3 pages

Lockout/Tagout (Loto) Checklist: 1. Scope of Work

This document is a lockout/tagout checklist that contains sections for equipment details, energy isolation points, stored energy dissipation, lockout sequence, and signatures. The checklist is used to establish and clear lockouts for equipment during maintenance to ensure worker safety.

Uploaded by

Putri Una
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
  • Lockout/Tagout Checklist Introduction
  • LOTO Sequence and Details
  • Signatures and Optional Pictures

Equipment Name: Equipment Owner:

Additional Contact(s): Facility / Building / Room:


     
Reviewed by: Approved by:

LOCKOUT/TAGOUT (LOTO) CHECKLIST


 
LOTO ESTABLISHED _____________________________________ LOTO CLEARED  _________________________________________
                                               signature / date / time                                       signature / date / time

1.     SCOPE OF WORK

2. ENERGY ISOLATION CHECKLIST

Electrical
# Equipment Descriptor Isolation Point Isolation Type Voltage-Type AF Energy / AF PPE Isolation Establishe Cleared
Boundary Position d (Initials) (Initials
)

Non-Electrical
# Equipment Descriptor Isolation Point Isolation Type Energy Source Pressure / Thermal PPE Isolation Establishe Cleared
/ Chemical Position d (Initials) (Initials
)

Energy Dissipation Devices


# Equipment Descriptor Dissipation Point Stored Energy Magnitude PPE Device Established Cleared
Type (Initials) (Initials)

    
 4.LOTO SEQUENCE (Select 4a, 4b or 4c as applicable)
4a.

4b:
 This LOTO Checklist requires the following LOTO Sequence:

4c:
This LOTO Checklist requires a specific sequence. Follow filedocument.pdf, attached.

5.  SIGNATURES
LOTO Authorized Person:
"I agree that the scope of work described in Section 1 falls within the LOTO Safe Zone established by the electrical electrical electrical
electrical isolations in Section 2. I have witnessed the implementation of the LOTO according to this permit and that zero energy
state was properly verified. By signing here I confirm that the LOTO has been fully established. "
 
____________________________________________________                          ______________
Print Name                                                                     Signature                              Date
 
Qualified personnel establishing the LOTO:
"I have implemented the LOTO according to this LOTO CHECKLIST and I have properly verified zero energy state."
____________________________________________________                          ______________
Print Name                                                                     Signature                              Date
 
____________________________________________________                          ______________
Print Name                                                                     Signature                              Date
 
____________________________________________________                          ______________
Print Name                                                                     Signature                              Date
6.      Pictures (optional)
 
 

 
 

      Equipment Name: Equipment Owner: Additional Contact(s): Facility / Building / Room: Reviewed by: Approved by: LOCKOU
 4. LOTO SEQUENCE (Select 4a, 4b or 4c as applicable) 4a. 4b:  This LOTO Checklist requires the following LOTO Sequence: 4c:
____________________________________________________                          ______________ Print Name                     

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