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General • Inspections

Hazardous Energy Control Procedures during LOTO

This procedure checklist is to protect employees from injuries while servicing and maintaining equipment.
MaintainX
07/26/2022

Hazardous Energy Control Procedures during LOTO

This procedure checklist is to protect employees from injuries while servicing and maintaining equipment.

    Name of employee exposed to the hazard:

    Machine / Equipment on which the task is being performed:

    Servicing / Maintenance task being performed:

    Frequency in which the employee performs the task:

    times per (days, weeks, months, etc.)

    Duration for which the employee has performed the task: _____ hour/day/week

    Hazard to which the employee is exposed when performing this task:

    caught in:

    crushed by:

    struck by:

    thrown from:

    contact with:

    other:

    Energy source which exposes the employee to a hazard:

    Magnitude of the energy source:

    Potential Injury associated with the improper isolation of energy:

    Crushed

    Fractured

    Amputated

    Lacerated

    Punctured

    Burns

    Air Embolism

    Death

    Electric Shock

    Other

    Means of Isolating the Energy Source (Procedures Used)

    Location:

    Method:

    If machine / equipment is not capable of lockout when was it installed, renovated, modified, or repaired (major)?

    • Yes
    • No
    • N / A

    If Electrical, cord / plug (circle one);

    • Yes
    • No
    • N / A

    Hazards discussed with exposed employee Mr. / Ms.

    Remarks/Signed Statement (if documenting past exposure) Hazard reviewed with employer Mr. / Ms.

    Remarks:

Source: MaintainX (Community Member)

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