Lockout/Tagout Verification
A field documentation tool for electricians, maintenance technicians, electrical contractors, and safety professionals applying lockout/tagout procedures before servicing equipment.
Customer / Company
*
Customer
Site Contact
Technician
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Customer Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Equipment & Energy Source Identification
Equipment & Energy Source Identification
Rows
YES
NO
N/A
Equipment or system identified
Energy sources identified
Electrical source identified
Mechanical energy sources considered
Hydraulic or pneumatic sources identified
Stored energy potential reviewed
Isolation points located
Work scope confirmed
Please provide photos of any "NO" selections
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Lockout Preparation
Lockout Preparation
Rows
Yes
No
N/A
Affected personnel notified
Equipment shutdown procedure followed
Energy isolating devices located
Isolation devices accessible
Proper lockout devices available
Proper tags available
Lockout devices inspected
Isolation plan reviewed
Please provide photos of any "NO" selections
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Lockout / Tagout Application
Lockout / Tagout Application
Rows
YES
NO
N/A
Energy sources isolated
Lock devices applied
Tagout devices applied
Multiple lock procedures used if required
Group lockbox used if required
Stored energy released
Equipment secured from movement
Lockout devices verified
Please provide photos of any "NO" selections
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Verification & Documentation
Verification & Documentation
Rows
YES
NO
N/A
Attempted start verification performed
Control switches returned to off position
Equipment confirmed de energized
Work area secured
Lockout maintained during work
Authorized personnel identified
Lock removal procedure reviewed
Findings documented
Please provide photos of any "NO" selections
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Notes
Write detailed notes about any items that were marked as "NO"
Customer Signature
Customer
Technician Signature
Technician
Take Photo
*
Office Email
Office Email
*
example@example.com
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