LOCKOUT/TAGOUT (LOTO) CHECKLIST

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--- 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

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