Run Lockout/Tagout Annual Periodic Inspection Form (Shop) — Free

Inspection Details

Inspection date critical (required)

Inspector is not one of the authorized employees being observed critical (required)

The periodic inspection must be performed by someone other than the employee(s) using the procedure.

Yes No N/A

Department / shop area

Machine / equipment name and asset ID critical (required)

Energy-control procedure identifier or document number critical (required)

Authorized employee(s) observed

Inspector signature critical (required)

Procedure Review

Procedure identifies all energy sources critical (required)

Procedure includes electrical, pneumatic, hydraulic, mechanical, thermal, gravitational, chemical, or stored energy sources as applicable.

Yes No N/A

Procedure identifies all isolation devices and their locations critical (required)

Yes No N/A

Procedure includes required sequence for shutdown, isolation, lockout, and release of stored energy critical (required)

Yes No N/A

Procedure includes verification of zero-energy state before work begins critical (required)

Verification must confirm isolation and dissipation of stored or residual energy before servicing or maintenance.

Yes No N/A

Procedure is legible, available at point of use, and matches the machine observed critical (required)

Yes No N/A

Authorized Employee Performance

Employee notifies affected employees before shutdown critical (required)

Yes No N/A

Equipment is shut down using the normal stopping procedure critical (required)

Yes No N/A

All energy-isolating devices are placed in the safe position critical (required)

Yes No N/A

Lockout devices and tags are applied by the authorized employee critical (required)

Yes No N/A

Stored or residual energy is relieved, restrained, or otherwise rendered safe critical (required)

Yes No N/A

Employee maintains control of keys and does not bypass the lockout device critical (required)

Yes No N/A

Verification and Release

Verification step performed to confirm zero-energy state critical (required)

Use an appropriate test or attempt-to-start method consistent with the procedure and equipment hazards.

Yes No N/A

Work area cleared of tools, parts, and nonessential personnel before re-energizing critical (required)

Yes No N/A

Affected employees notified before lockout/tagout devices are removed critical (required)

Yes No N/A

Lockout/tagout devices removed by the authorized employee who applied them critical (required)

Yes No N/A

Equipment restored to service in a controlled manner

Yes No N/A

Note (optional)

Findings and Corrective Actions

Deficiencies or non-conformances identified

Record any gaps in the procedure, observed deviations, missing devices, or training concerns.

Yes No N/A

Corrective actions documented with owner and due date

Procedure updated or reissued if needed

Yes No N/A

Note (optional)

Follow-up inspection required

Yes No N/A

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Run: Lockout/Tagout Annual Periodic Inspection Form (Shop)

Inspection Details

Procedure Review

Authorized Employee Performance

Verification and Release

Findings and Corrective Actions

Get your results