LOTO Program Annual Inspection and Training Assessment Checklist

Copy or customize this checklist from the University of Washington to meet the needs of your LOTO Annual Inspection and Training Assessment.

Department: ____________________________________________
Location: _______________________________________________
Equipment: _____________________________________________

Yes No Comments
Has there been a change in job assignments, machines, equipment or processes?
If so, have employees been re-trained when job assignments, machines, equipment or processes have changed?
Are the locks uniquely identified, uniquely keyed, and only used for the purpose of LOTO?
Does the tag used with the lock identify the worker servicing the machine or equipment?
Have equipment and machine-specific LOTO procedures been documented in writing?
Does the authorized employee know where the written LOTO procedures are located?
Does the authorized employee notify affected employees and all other employees in the area before starting the LOTO procedure?
Can the authorized employee identify all hazardous energy sources and associated hazards for the equipment or machine to be locked out?
Does the authorized employee follow the proper LOTO procedures for deenergizing the equipment or machine?
Does the authorized employee demonstrate the proper steps for the placement, removal and transfer of LOTO devices?
Does the authorized employee use the proper methods to verify the equipment or machine was de-energized?
Before releasing the machine or equipment from LOTO, does the authorized employee do the following:

A)     Inspect the machine or equipment to ensure it is operationally intact?

B)     Ensure that all employees are safely positioned?

C)     Notify affected employees and all other employees in the area that the LOTO devices have been removed?
If you answered “No” to questions 2-11, has the employee been retrained?

 

Lockout – Tagout Annual Inspection – Authorized Employees Observed (Please print)

Name Job Title Name Job Title
1   2  

 
3   4  

 
5   6  

 
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Deficiencies Observed and Corrective Actions: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date: _______________________________________________________________
Inspection Done By: ___________________________________________________

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