Lockout / Tagout Permit

Job and equipment

Date *

Site / location *

Job / project #

Equipment or system locked out *

Equipment ID / tag #

Customer contact (if at a customer site)

Reason for lockout (work to be done) *

Type of control

Method *

Lockout and tagTagout only (device cannot be locked)

Group lockout (more than one person locking on)? *

YesNo

Customer / host employer’s lockout procedure reviewed? *

YesNoN/A (our own equipment)

Energy sources and isolation points

List every source of energy to this equipment, where it is isolated, and the lock or tag number placed on it. Check Verified when you have proven that source is at zero energy.

#	Energy type	Isolation point / device	Magnitude	Lock / tag #	Stored energy relieved by	Verified
1
2
3
4
5
6
7
8

Application sequence

Do these in order. Any “No” means work does not start.

Step	Yes	No	N/A
Prepared: type and size of each energy, its hazards and how to control it are known (d)(1)
Affected employees notified that lockout / tagout is being applied and why
Equipment shut down by its normal stopping procedure (d)(2)
Every energy-isolating device needed has been operated (d)(3)
Lock and tag applied by an authorized employee at each isolating device (d)(4)
Stored or residual energy relieved, blocked, grounded or otherwise made safe (d)(5)
Isolation verified (tried to start / tested), then controls returned to OFF (d)(6)

How isolation was verified *

Verified by (print) *

Time verified *

Group lockout roster

If more than one person works under this lockout, one authorized employee has primary responsibility, confirms each person’s exposure, and each person places a personal lock on the group lockbox when starting and removes it when finished.

Primary authorized employee (print)

Group lockbox #

Number of locks on the box

#	Authorized employee (print)	Personal lock #	Lock on	Lock off
1
2
3
4
5
6
7
8
9
10

Shift or personnel change

Transfer protection with no gap. The oncoming employee places a lock before the off-going employee removes theirs.

Off-going authorized employee

Oncoming authorized employee

Time of transfer

Off-going authorized employee

Oncoming authorized employee

Time of transfer

Off-going authorized employee

Oncoming authorized employee

Time of transfer

Authorization

Authorized employee in charge (print) *

Employee ID

Date / time applied *

Authorized employee in charge — signature

Supervisor (print)

Employee ID

Date / time

Supervisor — signature (optional)

Release from lockout / tagout

Complete when the work is finished. Open this record again in edit mode to add the release; the original stays on file.

Step	Yes	No	N/A
Work area inspected; tools and nonessential items removed; equipment components intact (e)(1)
All employees are safely positioned or clear of the equipment (e)(2)
Affected employees told that locks / tags are being removed, before restart (e)(3)
Each lock and tag removed by the employee who applied it (e)(3)
Equipment energized for testing or repositioning with the (f)(1) sequence (N/A if none)

If a device was removed by someone other than the person who applied it, document who authorized it, how you confirmed the employee was not at the facility, and how they were told

Released by (print)

Employee ID

Date / time released

Released by — signature