How to Use

Use this form to conduct inspections of energy control procedures to ensure that equipment adequately satisifies lockout/tagout procedures. Inspections should be carried out by an authorized employee, other than the one(s) using the energy control procedures. During the inspection, the inspector should review the authorized employees’ responsibilities under the procedures being inspected.

Periodic inspections should:

• be certified
• identify the machine or equipment where the energy control procedures apply
• give inspection date
• list the employees included in the inspection
• state the person carrying out the inspection

Carry out periodic inspections of the energy control procedures at least annually. Keep documentation of inspections for at least a year.