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Lock out tag out procedure template

Use this lock-out tag-out procedure template before you repair industrial equipment. Record the kind of work, dangerous energy sources, and the workers involved in the procedure. Do a site walkthrough to assure that the area is free from unnecessary tools and verify if employees are qualified to perform a procedure. After that, check the quality and effectiveness of LOTO devices being used. Assess if the step-by-step method was followed when implementing and removing LOTO devices. Finally, rate the overall lockout tagout process and give recommendations with the use of this template.

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General Information
Kind of work
Workers involved in the LOTO:
Dangerous energy sources:
Purpose of this procedure
Attach a photo of the equipment/machinery/device:
Area Inspection
Have lockout or tagout devices been replaced from the energy-isolating device by the worker who used them?
Are all of the machine or equipment parts operationally functional?
Are all workers safely located or have cleared the area?
Have unimportant objects (e.g., tools, spare parts) been removed from the workspace?
Have all concerned employees been informed that the lockout or tagout devices have been removed before the machine started?
Have affected workers been trained to know when the procedure is being used and directed not to remove lockout/tagout devices or start de-energised equipment?
Are concerned employees informed when the procedure is being used?
Are the workers informed about the Lockout/Tagout procedures and their duties?
Lockout/Tagout Devices
Are they substantial enough to prevent removal without the application of excessive force?
Do they certainly identify the worker who established the device?
Are LOTO devices produced from durable supplies to stand the industrial environment of their application?
Applying LOTO devices
Are all active employees told that you are ready to start the LOTO procedure?
Is the equipment stopped by its standard shutdown procedure?
Is the equipment separated by turning off the energy at the central power source?
Have all sources of power been reviewed before turning off the machine?
Has the power been turned off and verified?
Are lock and proper lockout device (tags) used to each energy-isolating device?
Reference-image: Proper lockout and tagout device connected to the power source of the separate device. [This is an example of how you can use Lumiform to add reference images showing the best practice in your templates to help with inspections]
Removing LOTO devices
Are all tools removed and all machine guards replaced?
Are all workers cleared off the machine?
Is the LOTO equipment removed by the same person who applied them?
Are all concerned employees informed that LOTO devices have been removed?
Is energy restored appropriately?
Do you have any further recommendations?
Name and signature of the inspector:
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Lockout Tagout Procedure Template: Safeguarding Against Hazardous Energy

  A lockout tagout procedure template is a standardized document used to guide the proper implementation of lockout tagout (LOTO) procedures in workplaces. It outlines the necessary steps and precautions to ensure the isolation of hazardous energy sources, such as electrical, mechanical, or pneumatic, before performing maintenance or repair tasks on equipment. The template typically includes sections on equipment identification, energy source isolation, lockout tagout devices, verification procedures, and release protocols.   The usage of a lockout tagout procedure template is crucial for the safety of workers and compliance with regulations. By following this template, employers can establish a systematic approach to lockout tagout, reducing the risk of unexpected startup or release of stored energy during maintenance activities. The template provides clear instructions and requirements for employees to follow, ensuring that equipment is properly de-energized, isolated, and secured before work begins. It also emphasizes the importance of training, communication, and periodic inspections to maintain a safe work environment.
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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