/ Form 000.653.F0294
Lockout/Tagout Surveillance/Program Review
Date(s) of Surveillance/Program Review:
Project No./Contract No.: / Employer Name:
Names of Persons Conducting Surveillance/Review:
Written Lockout/Tagout Program Procedure Reviewed / Yes / No
List “authorized workers” interviewed for verification of lockout/tagout knowledge and requirements
Name of “Authorized Worker” / Dept. / Last LO/TO Training Date / Did Employee Have Lock/Tag/Hasp?
(Yes/No) / Knowledge of Lockout Hardware/Lockbox, Tags, Shift Changes, Group Lockouts, Types,and Magnitudes of Plant Energy Sources (Yes/No)
Actual lockout/tagout work witnessed — List “authorizedworkers”performing the work
Name of “AuthorizedWorker” / Dept. / Machine Locked Out / Machine-Specific ECP No. / ECP BeingFollowed? (Yes/No)
If “No,” employee name / Comments or Corrective Action Taken or Recommended
The following machine-specific ECPs have been reviewed for accuracy and posting
ECP No. / Machine or Equipment ID / Is ECP still accurate (verified) and posted?
(Yes/No) / If No, Describe Action Taken or Recommendations / List any ECPs Added or Other Comments
Review of lockout/tagout hardware (answer Yes or No)
Item / Lockout Tags / Lockboxes / Other Lockout Hardware/Devices
Is hardware being maintained?
Adequate supply on hand?
Good “authorized worker” knowledge of use and location of devices?
Properly stored or located?
Used only for lockout/tagout work?
Is there an effective lock key control program in place? Yes No.If “No,” action to be taken:
List “affected workers” interviewed to verify their knowledge
Name of “Affected Workers” / Job Title/Dept. / Notified Prior to LO/TO Work onEquipment They Operate? (Yes/No) / Do They Understand the Importance of not Attempting to Start Equipment that is Locked and Tagged Out? (Yes/No) / Do They Have a Clear Understanding of the Types and Magnitudes of the Hazardous Energy Sources?
(Yes/No)
Over the past year, has new or modified equipment or machinery been provided with energy-isolating devices that can accept a lockout lock, along with an ECP? Yes No N/A. If “No,” identify the action taken or to be taken:
Has the facility received any citations or penalties (or employee complaint letters) from a regulating entity the past year with regard to lockout/tagout? Yes No. If “Yes,” what was the corrective action that was taken to abate citation complaint, and is such action still being followed and taken?
Identify any other action items, recommendations to be taken, or overall comments as it relates to this surveillance.
Copyright © 2009, P2S. All Rights Reserved.
Form Date: 01May2009 / Page 1 of 2 / Health, Safety, and Environmental
/ Form 000.653.F0294
Lockout/Tagout Surveillance/Program Review

Note:This form is referenced in Practice000.653.3315.

Copyright © 2009, P2S. All Rights Reserved.
Form Date: 01May2009 / Page 1 of 2 / Health, Safety, and Environmental