Lockout Tagout Template - FREE Editable PDF | Lumiform

Lockout tagout template

About the Lockout tagout template

Using a lockout tagout template is essential for enhancing workplace safety and ensuring compliance with safety regulations. This template provides a structured approach to managing the lockout tagout process, which is crucial for preventing accidents during maintenance and repair activities.

By using this template, you can standardize procedures, ensuring consistency and reducing the risk of human error. The primary purpose of this template is to clearly document steps for isolating energy sources, ensuring that all team members understand and follow the correct procedures.

This not only protects employees from potential hazards but also enhances operational efficiency by minimizing downtime. Additionally, this LOTO template helps you maintain compliance with safety standards, avoiding costly fines and improving your organization’s safety culture. By implementing this tool, you ensure a safer working environment and demonstrate a commitment to employee well-being.

Key elements of a lockout tagout template

A lockout tagout template is designed to ensure safety and compliance during maintenance activities by effectively isolating hazardous energy sources. Here are the key elements that make this template effective:

Equipment identification: This section helps you clearly identify the machinery or equipment involved. Accurate identification is crucial for ensuring that the correct devices are locked out, preventing accidental activation.
Energy source isolation: Detail the specific steps required to isolate energy sources. This includes electrical, hydraulic, pneumatic, and other energy types. Providing clear instructions ensures that all potential hazards are addressed comprehensively.
Lockout/tagout device application: Describe the procedure for applying lockout and tagout devices. This step ensures that only authorized personnel can remove the devices, maintaining control over the equipment throughout the maintenance process.
Verification and testing: Include a section for verifying that all energy sources have been effectively isolated and that the equipment is safe to work on. Verification is essential for confirming that the lockout tagout process has been executed correctly.

When to use a lockout tagout template

A lockout tagout template is most beneficial during maintenance, repair, or servicing of machinery and equipment. Use this template whenever you need to ensure that hazardous energy sources are effectively isolated to prevent accidental activation. It’s particularly crucial in environments with complex machinery or multiple energy sources, where the risk of injury is higher.

You can also apply this checklist during routine safety audits to verify that lockout tagout procedures are being followed correctly. By using this template in these scenarios, you enhance workplace safety and ensure compliance with regulatory standards. This tool helps you standardize safety procedures, reducing the risk of accidents and fostering a culture of safety within your organization.

Categories

Health and safety management templates
Manufacturing templates
Workplace safety templates

Preview of the template

Audit

Program

Has the employer established a LOTO program?

Definitions

Does the procedure define the following items?1910.147(b) 1. Affected employees 2. Authorized employees 3. Energized 4. Capable of being locked out 5. Energy isolating device 6. Energy source 7. Lockout 8. Lockout device 9. Tagout 10. Tagout device

Content

Does the program contain energy control procedures or methods to determine energy control periods? 1910.147(c)(1)

Does the program contain employee training requirements for authorized and affected individuals? 1910.147(c)(1)

Does the program contain periodic inspection requirements? 1910.147(c)(1)

Does the procedure identify methods to be used when an energy isolating device cannot be used? 1910.147(c)(2)(i)

Does the program identify pracatuions and limitiations of using tagout only? 1910.147(c)(2)(ii)

Does the program identify LOTO design criteria for new equipment? 1910.147(c)(2)(iii)

Does the program contain the following sections? 1910.147(c)(4)(ii) 1. Scope of the program 2. Purpose of the program 3. Authorization 4. Rules and techniques for LOTO 5. A specific statement for the use of the procedure 6. Specific procedural steps for shutting down, isolating, blocking and securing machines or equipment to control hazardous energy 7. Specific procedural steps for the placement, removal and transfer of lockout devices or tagout devices and the responsibility for them 8. Specific requirements for verifying the effectiveness of lockout devices, tagout devices, and other energy controlling measures

Are materials provided by the employer for use as LOTO devices? 1910.147(c)(5)(i)

Equipment

Do LOTO devices meet the following criteria? 1910.147(c)(5)(ii)

Do LOTO devices meet the following criteria? 1910.147(c)(5)(ii) 1. Singularly identified 2. Used on on LOTO 3. Durable 4. Capable of withstanding the environment 5. Capable of becoming wet without deterioration 6. Capable of withstanding acidic or basic environments where acids or bases are stored 7. Standardized - Same color, design, shape, etc. Must meet one criteria 8. Substantial/Heavy Duty 9. Identifiable 10. Provide a warning to employees

Inspections

Does the employer conduct a periodic inspection of the energy control procedure at least annually to ensure that the procedure and the requirements of this standard are being followed? 1910.147(c)(6)(i)(A)

Does the employer conduct a periodic inspection that includes a review of each authorized employee's responsibilities under the program? 1910.147(c)(6)(i)(C)

Does the employer conduct a periodic inspection that includes the identification of the machine, the date of the inspection, the employees included in the inspection, and the person performing the inspection? 1910.147(c)(6)(ii)

Training

Does the employer provide training to authorized and affected employees? 1910.147(c)(7)(i)

Does the employer provide training that includes the understanding of the knowledge and skills required for safe use of LOTO? 1910.147(c)(7)(i)

Does the employer provide training that includes recognition of hazardous energy sources, types and magnitude of energy available in the workplace, and the methods of isolation? 1910.147(c)(7)(i)(A)

Does the employer provide training to affected individuals that includes the purpose and use of energy control procedures? 1910.147(c)(7)(i)(b)

Where tagout systems are used, does the employer provide training to the limitations of tagout only? 1910.147(c)(7)(ii)

Does the employer address address LOTO retraining and the conditions that retraining is required? 1910.147(c)(7)(iii)(A)

Does the employer track LOTO training including employees name and dates of training? 1910.147(c)(7)(iv)

LOTO Steps

Is lockout or tagout performed only by the authorized employee who is performing the maintenance? 1910.147(c)(8)

Do authorized employees follow the step-by-step process for LOTO? 1910.147(d) 1. Application of control 2. Preparation for shutdown 3. Machine shutdown 4. Machine isolation 5. LOTO application 6. Release of stored energy 7. Verification of isolation 8. Completion of maintenance 9. Release from LOTO 10. LOTO device removal

Does the program provide guidance for the testing or repositioning of machinery during LOTO? 1910.147(f)(1)

Does the program provide instructions for interactions with contractors? 1910.147(f)(2)

Does the program provide guidance for group LOTO? 1910.147(f)(3)

Does the program provide devices for group LOTO? 1910.147(f)(3)

Does the program provide instructions for shift change? 1910.147(f)(4)

Audit Score

90 - 100 Excellent: 1 or 2 minor deficiencies only

80 - 90 Average: No major, more than 2 minor deficiencies

70 - 80 Poor: Any major deficiency

Audit Score

Frequently asked questions

What is the purpose of a lockout tagout template?

A lockout tagout template is used to ensure the safe isolation of hazardous energy sources during maintenance activities. It provides a structured approach to prevent accidental machine activation, protecting workers from potential injuries and ensuring compliance with safety regulations.

How can a lockout tagout template improve workplace safety?

Using this tagout template improves workplace safety by standardizing procedures for isolating energy sources. It ensures that all steps are followed consistently, reducing the risk of human error and accidents. This fosters a culture of safety and enhances overall operational efficiency.

Who should use a lockout tagout template?

Maintenance personnel, safety officers, and facility managers should use this tagout template. It helps them ensure that all safety protocols are followed during equipment servicing, protecting workers and maintaining compliance with safety standards.

When is the best time to implement a lockout tagout procedure?

The best time to implement a lockout tagout procedure is before any maintenance, repair, or servicing work begins on machinery. It’s also beneficial during routine safety audits to ensure that all procedures are up-to-date and effectively protecting workers from hazards.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.