Lock Out/ Tag Out Inspection Form

Project Name:____________________________________ Project Number:_________________

1. Inspection Conducted by:______________________________on____________________________
2. Machines/Equipment Inspected:_______________________________________________________
____________________________________________________________________________________
3. Names of Employees Checked:_______________________________________________________
___________________________________________________________________________________
4. Deficiencies Notes:___________________________________________________________________
___________________________________________________________________________________
5. Corrective Action Taken:______________________________________________________________
____________________________________________________________________________________
YES NO
6. Have employees (contractors) been trained/instructed in our
lockout procedure? ________ ________
7. Are lock and/or tag devices authorized by the company
procedure? ________ ________
8. Are all effected employees (contractors) notified that a
lockout is required and the reason for it? ________ ________
9. Is equipment being shut down by required shutdown
procedure? ________ ________
10. Are the switches, valves, or other energy isolating devices
disconnected or isolated from the equipment? ________ ________
11. Are the energy isolating devices located out/tagged out
by an authorized employee’s individual lock/tag? ________ ________
12. Are the push buttons or other normal operating controls
checked to see if the energy sources are disconnected
and that the equipment cannot operate? ________ ________

13. Are equipment areas checked to see that personnel are

not in the area and all locks/tags are removed? ________ ________

14. If more than on individual is required to lockout

equipment, does each person place his/her own
personal lock/tag on the energy isolating deivce(s)?
Are all steps of group lockout/tagout procedures
observed? ________ ________
15. If an employee or contractor is not available to clear
his/her lock/tag, does the supervisor remove the
lock/tag after taking all the precautions listed in our
lockout/tagout program? ________ ________

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Health and Safety Program