Mma prevent loto lockout-tagout shut-down procedure checklist
Lock out tag out procedures
What does this form include?
This form contains 12 sections:
Equipment Name/Model Number:
Photograph of equipment:
Scope: Utilize this procedure for any maintenance or servicing of aforementioned equipment: Purpose:
Type of Energy
Describe where the energy isolation point is located:
Photo of where the energy isolation point is located:
Describe how to disconnect (de-energize) this energy source:
Identify the device required for lockout/tagout:
Lockout Removal Process: 1 - Inspect the work area to verify all tools, equipment, and materials have
Developed/Reviewed By (Name):
Periodic inspection conducted by:
Date of Lockout Creation / Update / Review: Date
Use this template