Free Workplace Lockout%2FTagout Procedure Form Template

Workplace Lockout/Tagout Procedure Form

Please fill out the form with your information below.

Enter your full name as appears on your company ID.

Please provide your company-issued employee ID number.

Select the date when the lockout/tagout procedure was conducted.

Choose the department where the lockout/tagout procedure is taking place.

List all equipment involved in the lockout/tagout procedure.

Notification: Notify all affected employees that a lockout/tagout procedure is going to be implemented and the reason for it.
Identification: Clearly identify the equipment or machinery to be locked out.
Shutdown: Turn off the equipment following the standard shutdown procedure.
Isolation: Isolate the equipment from its energy source(s).
Lockout/Tagout Application: Apply lockout/tagout devices to each energy isolation point.
Stored Energy: Ensure that any stored energy (electrical, mechanical, hydraulic, etc.) is released or restrained.
Verification: Verify that the equipment is isolated from its energy source by attempting to operate it.

Select all authorized personnel involved in the procedure.

Have all isolation points been physically verified?

Specify the types of lockout devices utilized.

Are there any additional procedures needed?

[Authorized Employee Name]

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