Lockout/Tagout (LOTO) Checklist

LOCKOUT/TAGOUT (LOTO) CHECKLIST Created by ChecklistGuro (https://checklistguro.com) --- PRE-SHIFT PLANNING & HAZARD ASSESSMENT --- [ ] Date of Assessment [ ] Time of Assessment Start [ ] Brief Description of Task/Job to be Performed [ ] Potential Hazards Identified (Initial Assessment) [ ] Hazards Related to Previous Incidents/Near Misses? (Yes, No, Unknown) [ ] Previous Control Measures (if any) & Their Effectiveness [ ] Risk Level (Based on Initial Assessment) (Low, Medium, High) [ ] Name of Person Performing Hazard Assessment [ ] Signature of Person Performing Hazard Assessment --- IDENTIFY ENERGY SOURCES --- [ ] What types of energy are present? (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. [ ] Voltage of electrical supply (if applicable) [ ] Pressure of pneumatic/hydraulic systems (if applicable) [ ] Identify the primary energy source requiring isolation. (Electrical, Pneumatic, Hydraulic, Mechanical, Thermal, Chemical) [ ] Additional Notes about Energy Sources (e.g., secondary hazards) --- ISOLATION & SHUTDOWN PROCEDURES --- [ ] Detailed Step-by-Step Shutdown Procedure [ ] Equipment ID Number [ ] Shutdown Sequence (e.g., Normal Stop, Emergency Stop) (Normal Stop, Emergency Stop, Controlled Shutdown) [ ] Location of Primary Isolation Point [ ] Date of Procedure Review/Update (Last Reviewed) [ ] Time of Shutdown Initiation [ ] Any Unusual Considerations for Shutdown? --- LOCKOUT/TAGOUT APPLICATION --- [ ] Lock Type Used (e.g., Keyed, Combination) (Keyed Lock, Combination Lock, Other (Specify in LONG_TEXT)) [ ] Lock ID Number [ ] Tag Type Used (Standard Tag, Custom Tag, Blank Tag (To be filled)) [ ] Tag ID Number [ ] Tag Information [ ] Lock/Tag Location (Specific Point of Isolation) [ ] Authorized Personnel Applying LOTO (Single Authorized Person, Multiple Authorized Persons, Group Lockout Procedure) [ ] Authorized Personnel Signature (Lock Application) --- VERIFICATION OF ISOLATION --- [ ] Voltage Reading (Phase-to-Phase) [ ] Voltage Reading (Phase-to-Neutral) [ ] Current Reading (Amps) [ ] Confirm Zero Energy State? (Yes, No) [ ] Describe Verification Steps Taken [ ] Sound Check (Confirm no equipment noise) (Yes, No) [ ] Movement Check (Confirm no unintended movement) (Yes, No) [ ] Verification Date [ ] Verification Time --- WORK PERFORMANCE & OBSERVATION --- [ ] Describe the work being performed on the equipment. [ ] Number of personnel working on the equipment. [ ] Are there any unusual noises or movements observed? (Yes, No) [ ] If yes, describe the unusual noises or movements. [ ] Were any tools or equipment accidentally moved or dropped during the work? (Yes, No) [ ] If yes, describe the incident and corrective actions taken. [ ] Is anyone experiencing discomfort or noticing anything concerning? (Yes, No) [ ] If yes, describe the discomfort or concern. --- REMOVAL OF LOTO & EQUIPMENT RESTART --- [ ] Date of LOTO Removal [ ] Time of LOTO Removal [ ] Reason for LOTO Removal (Completion of Work, Shift Change, Equipment Malfunction, Other (Specify)) [ ] If 'Other' selected, please explain reason for removal [ ] Was a visual inspection performed? (Yes, No) [ ] Equipment Voltage/Pressure after Verification [ ] Confirmation of Clear Communication with Affected Personnel (Yes, No) [ ] Authorized Personnel Signature (Removal) [ ] Name (Printed) of Authorized Personnel --- DOCUMENTATION & SIGN-OFF --- [ ] Date of LOTO Procedure [ ] Time of LOTO Implementation [ ] Equipment/Machine ID [ ] Brief Description of Work Performed [ ] LOTO Procedure Followed (Reference) (Standard Procedure A, Standard Procedure B, Custom Procedure - Specify in Notes) [ ] Additional Notes/Observations [ ] Authorized Lockout Person Signature [ ] Affected Employee Acknowledgement --- END OF TEMPLATE --- Transform this text into a digital, automated, and trackable mobile app! Visit: https://checklistguro.com/templates/manufacturing/lockout-tagout-loto-checklist (Click "Install Template" to launch your digital inspection tool immediately)