OSHA - LOTO Print to Fill Form

Requirements:

Computer & printer
Computer Skills: low

General Information:

This is a Microsoft Word file that can be printed and filled out.

The content is arranged in a table format and can be edited in Microsoft Word.

This form is made to print and fill out by hand for those not comfortable filling it out on the computer.

Instructions:

Download forms from the website and print. Or download the forms, save and then print.
Fill in the blanks and tables with appropriate information. See the LOTO Procedures EXAMPLE 2 for help.
Secure appropriate pictures to the “LOTO Specific Instructions” form.
Make copies.

LOTO PROCEDURES

Company Name

Lock out/Tag Out procedures are to be completed before any service or maintenance work on equipment or machinery, and/or before entry into any grain bin or other area where operating equipment poses a hazard to the entrant. Failure to follow proper lockout-tag out procedures may result in disciplinary action up to and including termination.

Each LOTO will follow the general process listed below

LOTO will follow the specific instructions for each piece of equipment/machinery to identify, disconnect, isolate, lock out and verify the lock out of the appropriate energy sources.

Ending LOTO – follow the general LOTO Release process listed below, using the specific instructions for the equipment to activate energy sources

General Lockout Steps

Steps & Instructions

Notify Employees: Notify all affected employees what machine/equipment will be shutdown and locked out.
Review Procedures: Ensure each person performing LOTO (authorized employee) understands the type and magnitude of the energy present, the associated hazards and the proper methods of control.
Shutdown Equipment: If the machine or equipment is operating, shut it down by the normal stopping procedure.
Disconnect & Isolate the Energy Source: Disconnect/de-activate the energy isolating devices(s) so the machine or equipment is isolated from the energy source(s).
Lockout Controls: Lockout and tag out the energy isolating device(s) as indicated in the specific instructions
Release Energy: Release and/or dissipate any stored or residual energy as indicated in the specific instructions.
Try out: Verify the energy source has been isolated as indicated in specific instructions.

Additional Information

Lockout Release Steps

Steps & Instructions

Inspect Equipment: Check the equipment to ensure the components are operational.
Check Area: Check the immediate area to ensure all employees have been safely positioned, and tools and any nonessential items have been removed.
Check Controls: Verify that operating controls are off (not on).
Re-energize: Remove the lockout device(s) and activate the energy isolating device(s) to re-energize the equipment
Notify Employees: Notify affected employees the servicing or maintenance is completed and the equipment is ready for use.
Startup Equipment: Startup equipment and monitor for several operating cycles to ensure it is functioning properly.

SPECIFIC LOTO INSTRUCTIONS

Company Name

Equipment ID:

Description:

Facility:

Location:

Date Created:

Person:

Date Revised:

Person:

# 1 Lockout Points Identify where the lock out points are located.

Picture of lockout points goes here.

Add or drag pictures

Picture of lockout points goes here.

Add or drag pictures

# 2 Lockout Instructions Follow the lock out instructions below.

Any machine modifications must be shown in this procedure. Contact facility manager to update this procedure. Always perform a machine stop before locking out disconnects.

Energy Source

Device used to De-energize

Location

Method

Try Out Check to Verify Equipment is De-energized

SPECIAL INSTRUCTIONS

1.

2.

3. Reference: Typical minimal lockout procedure – 29 CFR 1910.147 App. A Enforcement: Failure to follow proper lockout-tag out procedures may result in disciplinary action up to and including termination.

SAFETY IS YOUR RESPONSIBILITY – LOCK IT OUT!

Requirements:

Computer & printer

Computer Skills: low

General Information:

This is a Microsoft Word file that can be printed and filled out.

The content is arranged in a table format and can be edited in Microsoft Word.

This form is made to print and fill out by hand for those not comfortable filling it out on the computer.

Instructions:

Download forms from the website and print. Or download the forms, save and then print.

Fill in the blanks and tables with appropriate information. See the LOTO Procedures EXAMPLE 2 for help.

Secure appropriate pictures to the “LOTO Specific Instructions” form.

Make copies.

LOTO PROCEDURES

Company Name

Each LOTO will follow the general process listed below

LOTO will follow the specific instructions for each piece of equipment/machinery to identify, disconnect, isolate, lock out and verify the lock out of the appropriate energy sources.

Ending LOTO – follow the general LOTO Release process listed below, using the specific instructions for the equipment to activate energy sources

General Lockout Steps

Steps & Instructions

Notify Employees: Notify all affected employees what machine/equipment will be shutdown and locked out.

Review Procedures: Ensure each person performing LOTO (authorized employee) understands the type and magnitude of the energy present, the associated hazards and the proper methods of control.

Shutdown Equipment: If the machine or equipment is operating, shut it down by the normal stopping procedure.

Disconnect & Isolate the Energy Source: Disconnect/de-activate the energy isolating devices(s) so the machine or equipment is isolated from the energy source(s).

Lockout Controls: Lockout and tag out the energy isolating device(s) as indicated in the specific instructions

Release Energy: Release and/or dissipate any stored or residual energy as indicated in the specific instructions.

Try out: Verify the energy source has been isolated as indicated in specific instructions.

Additional Information

Lockout Release Steps

Steps & Instructions

Inspect Equipment: Check the equipment to ensure the components are operational.

Check Area: Check the immediate area to ensure all employees have been safely positioned, and tools and any nonessential items have been removed.

Check Controls: Verify that operating controls are off (not on).

Re-energize: Remove the lockout device(s) and activate the energy isolating device(s) to re-energize the equipment

Notify Employees: Notify affected employees the servicing or maintenance is completed and the equipment is ready for use.

Startup Equipment: Startup equipment and monitor for several operating cycles to ensure it is functioning properly.

SPECIFIC LOTO INSTRUCTIONS

Company Name

Equipment ID:

Description:

Facility:

Location:

Date Created:

Person:

Date Revised:

Person:

# 1 Lockout Points Identify where the lock out points are located.

Picture of lockout points goes here.

Picture of lockout points goes here.

# 2 Lockout Instructions Follow the lock out instructions below.

Any machine modifications must be shown in this procedure. Contact facility manager to update this procedure. Always perform a machine stop before locking out disconnects.

Energy Source

Device used to De-energize

Location

Method

Try Out Check to Verify Equipment is De-energized

SPECIAL INSTRUCTIONS

1.

2.

3.

Reference: Typical minimal lockout procedure – 29 CFR 1910.147 App. A Enforcement: Failure to follow proper lockout-tag out procedures may result in disciplinary action up to and including termination.

SAFETY IS YOUR RESPONSIBILITY – LOCK IT OUT!