Lockout/Tagout Authorized Employee Evaluation Form

Facility

Date

Equipment / Process Name

Machine Specific LOTO procedure name

Inspector

Inspector’s signature

Authorized Employee

Authorized Employee’s signature

Does the authorized employee understand how/where to access the lockout/tagout procedure?

• Yes
• No
• N / A

Was the equipment or system properly shutdown at each hazardous energy source?

• Yes
• No
• N / A

Did the authorized employee apply locks, devices, and tags to each energy isolation device?

• Yes
• No
• N / A

Did the authorized employee apply warning tags to each energy isolation device identifying their name, department or shop, and contact information?

• Yes
• No
• N / A

Was a warning tag used in place of a lock? If so, was it obvious to anyone in the area that the equipment or system must not be started up?

• Yes
• No
• N / A

Did the authorized employee properly dissipate or control hazardous energy?

• Yes
• No
• N / A

Are the verification methods effective and complete prior to starting servicing and maintenance (i.e., attempt restart, drain/bleed, check gauges, etc.)?

• Yes
• No
• N / A

Was the startup procedure effective and completed properly at the completion of servicing and maintenance?

• Yes
• No
• N / A

Did the authorized employee understand their responsibilities under the procedure?

• Yes
• No
• N / A

Were all steps in the procedure effective to safely shutdown and lockout/tagout hazardous energy to the equipment or system?

• Yes
• No
• N / A

The lockout/tagout procedure is adequate and provides the necessary protection with no corrective actions needed.

• Yes
• No
• N / A

If no, please list the required corrective actions below.