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:
Energy source which exposes the employee to a hazard:
Magnitude of the energy source:
Potential Injury associated with the improper isolation of energy:
Means of Isolating the Energy Source (Procedures Used)
If machine / equipment is not capable of lockout when was it installed, renovated, modified, or repaired (major)?
If Electrical, cord / plug (circle one);
Hazards discussed with exposed employee Mr. / Ms.
Remarks/Signed Statement (if documenting past exposure) Hazard reviewed with employer Mr. / Ms.
Source: MaintainX (Community Member)