Lockout/Tagout (LOTO) Checklist
Download our free Lockout/Tagout (LOTO) Checklist to streamline safety protocols and boost operational productivity using ChecklistGuro's automated workflows.
| Label | Value | Notes |
|---|---|---|
| Created by checklistguro.com | ||
| Pre-Shift Planning & Hazard Assessment (STEP) | ||
| Date of Assessment (DATE) | ||
| Time of Assessment Start (DATE) | ||
| Brief Description of Task/Job to be Performed (TEXT) | ||
| Potential Hazards Identified (Initial Assessment) (TEXT) | ||
| Hazards Related to Previous Incidents/Near Misses? (SELECTION options: Yes, No, Unknown) | ||
| Previous Control Measures (if any) & Their Effectiveness (TEXT) | ||
| Risk Level (Based on Initial Assessment) (SELECTION options: Low, Medium, High) | ||
| Name of Person Performing Hazard Assessment (TEXT) | ||
| Signature of Person Performing Hazard Assessment (SIGNATURE) | ||
| Identify Energy Sources (STEP) | ||
| What types of energy are present? (SELECTION options: Electrical, Pneumatic, Hydraulic, Mechanical (e.g., rotating shafts), Thermal (e.g., steam, hot oil), Chemical (e.g., pressurized vessels), Gravitational (e.g., elevated loads), None) | ||
| Describe any unusual or non-standard energy sources. (TEXT) | ||
| Voltage of electrical supply (if applicable) (NUMBER) | ||
| Pressure of pneumatic/hydraulic systems (if applicable) (NUMBER) | ||
| Identify the primary energy source requiring isolation. (SELECTION options: Electrical, Pneumatic, Hydraulic, Mechanical, Thermal, Chemical) | ||
| Additional Notes about Energy Sources (e.g., secondary hazards) (TEXT) | ||
| Isolation & Shutdown Procedures (STEP) | ||
| Detailed Step-by-Step Shutdown Procedure (TEXT) | ||
| Equipment ID Number (NUMBER) | ||
| Shutdown Sequence (e.g., Normal Stop, Emergency Stop) (SELECTION options: Normal Stop, Emergency Stop, Controlled Shutdown) | ||
| Location of Primary Isolation Point (LOCATION) | ||
| Date of Procedure Review/Update (Last Reviewed) (DATE) | ||
| Time of Shutdown Initiation (DATE) | ||
| Any Unusual Considerations for Shutdown? (TEXT) | ||
| Lockout/Tagout Application (STEP) | ||
| Lock Type Used (e.g., Keyed, Combination) (SELECTION options: Keyed Lock, Combination Lock, Other (Specify in LONG_TEXT)) | ||
| Lock ID Number (NUMBER) | ||
| Tag Type Used (SELECTION options: Standard Tag, Custom Tag, Blank Tag (To be filled)) | ||
| Tag ID Number (NUMBER) | ||
| Tag Information (TEXT) | ||
| Lock/Tag Location (Specific Point of Isolation) (LOCATION) | ||
| Authorized Personnel Applying LOTO (SELECTION options: Single Authorized Person, Multiple Authorized Persons, Group Lockout Procedure) | ||
| Authorized Personnel Signature (Lock Application) (SIGNATURE) | ||
| Verification of Isolation (STEP) | ||
| Voltage Reading (Phase-to-Phase) (NUMBER) | ||
| Voltage Reading (Phase-to-Neutral) (NUMBER) | ||
| Current Reading (Amps) (NUMBER) | ||
| Confirm Zero Energy State? (SELECTION options: Yes, No) | ||
| Describe Verification Steps Taken (TEXT) | ||
| Sound Check (Confirm no equipment noise) (SELECTION options: Yes, No) | ||
| Movement Check (Confirm no unintended movement) (SELECTION options: Yes, No) | ||
| Verification Date (DATE) | ||
| Verification Time (DATE) | ||
| Work Performance & Observation (STEP) | ||
| Describe the work being performed on the equipment. (TEXT) | ||
| Number of personnel working on the equipment. (NUMBER) | ||
| Are there any unusual noises or movements observed? (SELECTION options: Yes, No) | ||
| If yes, describe the unusual noises or movements. (TEXT) | ||
| Were any tools or equipment accidentally moved or dropped during the work? (SELECTION options: Yes, No) | ||
| If yes, describe the incident and corrective actions taken. (TEXT) | ||
| Is anyone experiencing discomfort or noticing anything concerning? (SELECTION options: Yes, No) | ||
| If yes, describe the discomfort or concern. (TEXT) | ||
| Removal of LOTO & Equipment Restart (STEP) | ||
| Date of LOTO Removal (DATE) | ||
| Time of LOTO Removal (DATE) | ||
| Reason for LOTO Removal (SELECTION options: Completion of Work, Shift Change, Equipment Malfunction, Other (Specify)) | ||
| If 'Other' selected, please explain reason for removal (TEXT) | ||
| Was a visual inspection performed? (SELECTION options: Yes, No) | ||
| Equipment Voltage/Pressure after Verification (NUMBER) | ||
| Confirmation of Clear Communication with Affected Personnel (SELECTION options: Yes, No) | ||
| Authorized Personnel Signature (Removal) (SIGNATURE) | ||
| Name (Printed) of Authorized Personnel (TEXT) | ||
| Documentation & Sign-off (STEP) | ||
| Date of LOTO Procedure (DATE) | ||
| Time of LOTO Implementation (DATE) | ||
| Equipment/Machine ID (NUMBER) | ||
| Brief Description of Work Performed (TEXT) | ||
| LOTO Procedure Followed (Reference) (SELECTION options: Standard Procedure A, Standard Procedure B, Custom Procedure - Specify in Notes) | ||
| Additional Notes/Observations (TEXT) | ||
| Authorized Lockout Person Signature (SIGNATURE) | ||
| Affected Employee Acknowledgement (SIGNATURE) | ||
Found this Media helpful?
