Lockout Tagout Verification
Equipment Identification
Equipment ID
Location
Energy Sources Identified
Voltage Level
Amps
Weight or Pressure
Isolation Steps Completed
Check all that apply:
Disconnect opened
Red (personal) lock applied
Yellow (transition) lock applied
Tag applied
Stored energy released
Mechanical restraints applied
Valve closed
Blank installed
Verification
Check all that apply:
Test start attempted
Live-Dead-Live completed
Zero pressure verified
Lead Authorized Employee
First Name
Last Name
Lead Authorized Employee Signature
Date/Time Lock & Tag Applied by Lead Authorized Employee
-
Month
-
Day
Year
Date
Please use 24-hour time
Verified By (Authorized Employee)
First Name
Last Name
Verifying Employee Signature
Group Lockbox (if applicable)
Number of Workers Applying Locks
Lockbox ID
Worker 1 Name
First Name
Last Name
Worker 1 Lock & Tag Number
Date/Time Worker 1 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker Lock 1 & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 2 Name
First Name
Last Name
Worker 2 Lock & Tag Number
Date/Time Worker 2 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 2 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 3 Name
First Name
Last Name
Worker 3 Lock & Tag Number
Date/Time Worker 3 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 3 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 4 Name
First Name
Last Name
Worker 4 Lock & Tag Number
Date/Time Worker 4 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 4 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 5 Name
First Name
Last Name
Worker 5 Lock & Tag Number
Date/Time Worker 5 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 5 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 6 Name
First Name
Last Name
Worker 6 Lock & Tag Number
Date/Time Worker 6 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 6 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 7 Name
First Name
Last Name
Worker 7 Lock & Tag Number
Date/Time Worker 7 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 7 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 8 Name
First Name
Last Name
Worker 8 Lock & Tag Number
Date/Time Worker 8 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 8 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 9 Name
First Name
Last Name
Worker 9 Lock & Tag Number
Date/Time Worker 9 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 9 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Worker 10 Name
First Name
Last Name
Worker 10 Lock & Tag Number
Date/Time Worker 10 Lock & Tag Applied
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time Worker 10 Lock & Tag Removed
-
Month
-
Day
Year
Date
Please use 24-hour time
Date/Time of Removal of Lead Authorized Employee Lock & Tag
-
Month
-
Day
Year
Date
Please use 24-hour time
Removal Authorization
Supervisor Verification Before Re-Energization
Supervisor Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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Should be Empty: