Lockout/Tagout Procedure Number
Machine or Equipment
Date of inspection
This equipment, its energy isolating devices, involved personnel, and applicable energy control procedure have been inspected and evaluated. The conclusions are:
Are the steps in the LOTO procedure being followed?
Do the employees involved know their responsibilities under the procedure?
Does the procedure provide the necessary protection?
Are changes to the procedure needed?
Note corrective actions and/or recommendations
Source: Ergon - Lubbock 14842 (Community Member)