LOCKOUT/TAGOUT CHECKLIST
LOCKOUT/TAGOUT CHECKLIST
Prior to beginning work on machinery, equipment, or systems requiring Lockout/Tagout, check each item. If there are items that are not applicable to the entry, mark them "N/A".
| Job Site: | Date: | Time: | |
|---|---|---|---|
| Foreman: | Exp. Date: | Exp. Time: |
PERSONAL PROTECTIVE EQUIPMENT
| □Hard Hat |
|---|
| □Eye/Face Protection (type) |
| □Protective clothing (type) |
| □Gloves (type) |
| □Respirator (type) |
| □Fall protection / Other |
SHUTDOWN & LOCKOUT
| $$ | Electrical lockout/tagout completed |
|---|---|
| $$ | Valves closed,lockout/tagout completed |
| $$ | Lines blinded/blocked off |
| $$ | Lines disconnected |
| $$ | Line bleeders open |
| $$ | All hydraulic/pneumatic pressure released |
| $$ | All other energy released and/or guarded(magnetic,spring,gravity,reactivity) |
| $$ | Hot work permit completed |
| $$ | System/area check for flammables/vapors |
| $$ | Fire extinguisher on site/in area |
| $$ | Barricade/Exclusion Zone markers in place |
| $$ | Machine/Equipment/System users /other personnel notified |
REACTIVATION
| $$ | Electrical/System reconnected |
|---|---|
| $$ | Line blinds/block-offs removed |
| $$ | Line breeders closed |
| $$ | Guards reinstalled |
| $$ | Tools/materials removed |
| $$ | Machine/Equipment/System users / other personnel clear and safe |
| $$ | Electrical lockout/tagout removed |
| $$ | Valve(s) lockout/tagout removed |
WORK TEAM
Print Initial
Foreman Safety Customer
JOB COMPLETED
Date: Time:
C:\Users\kristine.puccio\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\SV9VELAM\Lockout Tagout Checklist.doc Page 2 of 2 Date: 10/26/2023 12:06 PM Last Modified by: mscott