# 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