Company Name and Logo

Company Name and Logo

LOCKOUT VERIFICATION CHECKLIST

Reporting Employee
Employee Name: / Date: / r
r / Ad Hoc
Actual
Supervisor Name: / Equipment Being Locked Out:
Observations
Does the employee know what equipment is to be locked out? / r YES / r NO
Does the employee know the different types of lockouts for the equipment? (example: Air, Gravity, Hydraulic, Mechanical) / r YES / r NO
Did the employee demonstrate how to properly lockout the equipment? / r YES / r NO
Did the employee remove the key from the lock and put it in his/her pocket? / r YES / r NO
Did the employee test the equipment after lockout? / r YES / r NO
Are the lockout procedures available for reference? / r YES / r NO
Notes or Corrective Actions (Address all “NO” Selections from Above)
Signatures
Employee Signature:
Supervisor Signature:
r Employee Copy Issued
r Form Cover Updated

SAFETY OBSERVATION REPORT

Observed Employee
Name: / Area:
Crew: / Date:
Nature of Issue / + / - / PPE Evaluation / N/A / + / -
Stopped Working / NO / YES / Hard Hat
Changing Methodology / NO / YES / Eye Protection
Adjusting PPE / NO / YES / Hearing Protection
Other / Respiratory Protection
Housekeeping / + / - / HI-Vis Clothing
Clear of Slip/Trip/Fall Hazards / YES / NO / Gloves
Free of Plastic Contaminants / YES / NO / Safety Toe Boots
Other / Other
Other / Other
Procedures / + / - / Tools & Equipment / + / -
Being Followed / YES / NO / Correct for the Job / YES / NO
Available / YES / NO / Used Properly / YES / NO
Adequate for Task / YES / NO / In Good Condition / YES / NO
Other / Other
Positive Observations / Negative Observations
Corrective Action / Person Responsible / Due Date / Complete (initial) / Carried Forward
r
r
Observation Conducted By / Records
Name: / r / Employee Copy Issued
r / Form Cover Updated

Provided by Timber Products Manufacturers Association www.timberassociation.com