## 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:**