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Lockout Sheet

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Julien Doueihi
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22 views1 page

Lockout Sheet

Uploaded by

Julien Doueihi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

LOCKOUT SHEET

This form must be completed by the employer or the person in charge BEFORE the work begins.

IDENTIFICATION
Sheet no.:

Padlock placement date: Collection date:

Equipment concerned: Location:

Works to be executed:

RISKS PREVENTIVE MEASURES

Falling people or falling objects Facial protection


Physical attackers Ear protection
Contaminants Respiratory protection
Equipment in motion Other equipment PPE:
Electrical risk Collective protection
Mechanical risk Safety harness
Others Others

ENERGY RESETTING
LOCATING THE METHOD OF LOCKOUT
ENERGY LOCKOUT EQUIPMENT
CUT-OFF POINT AND RELEASE OF ENERGIES

Start-up test: Yes No

UNLOCKING AND REACTIVATION


LOCATING THE
ENERGY UNLOCKING INSTRUCTION REMOVING LOCKOUT MATERIAL
CUT-OFF POINT

Completed: Yes No

NOTES

Name of authorized worker Signature Date

Name of lockout manager Signature Date

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