Lockout / Tagout - Ohio Bureau of Workers' Compensation

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APPENDIX A – SAMPLE FORMS Form No. 1 – Energy Control Device Survey Form No. 2 – Written Procedure Elements Form No. 3 – Posted Procedure Checklist Form No. 4 – Lockout Application Inspection Checklist Form No. 5 – Lockout Removal Inspection Checklist Form No. 6 – Abandoned Lockout Devise Removal Permit
Form No.1 ENERGY CONTROL DEVICE SURVEY Name/number identification of machine/process/equipment ____________________________________ Location of machine/process/equipment ___________________________________________________ List every energy control device NOT CAPABLE of accepting lockout devices: _____________________ ____________________________________ ______________________________________ ____________________________________ ______________________________________ ____________________________________ ______________________________________ List alternate control measures/methods used: ______________________________________________ ____________________________________ ______________________________________ ____________________________________ ______________________________________ ____________________________________ ______________________________________ Specify corrective action required for each energy control device listed above: _____________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ Name of person responsible for corrective action ____________________________________________ ___________________________________________________________________________________ Date and time notified _________________________________________________________________ Date and time Local Joint Committee notified _______________________________________________ (THIS FORM MUST BE RETAINED BY ______________________________________________ (name of responsible member of management) FOR A PERIOD OF ONE YEAR FROM THE DATE OF COMPLETION). Signature of person performing survey ____________________________________________________ Name and title in full __________________________________________________________________ Date and time of survey _______________________________________________________________
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Lockout / Tagout Class Agenda and O
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Lockout / Tagout Course Objectives
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Activity Plan q Activity Other peop
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The following accidents, taken from
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V. Identify Different Personnel u A
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XI. Miscellaneous Items in Your Pro
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OSHA Regulations (Standards - 29 CF
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(a)(3) "Purpose." (a)(3)(i) This se
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(c)(2) "Lockout/tagout." (c)(2)(i)
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(c)(5)(ii) Lockout devices and tago
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(c)(7)(i)(A) Each authorized employ
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(d)(2) (d)(3) (d)(4) "Machine or eq
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(e)(3)(ii) Making all reasonable ef
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(7) Ensure that the equipment is di
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III. Definitions Authorized employe
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D. Lockout Device Application. 1. A
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3. Ensure that our employees unders
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APPENDIX A TAGOUT PROCEDURES A. Whe
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DATE: _____/_____/_____ APPENDIX C
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APPENDIX E ENERGY SOURCE EVALUATION
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2 of 3 APPENDIX F 5. A. Apply locks
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APPENDIX G-1 “Authorized” Emplo
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APPENDIX G-3 “Other” Employee T
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HAZARDOUS ENERGY CONTROL PROCEDURES
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Appendix I Audit Checklist Review t
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Yes No Before the machinery is acti
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Additional Training for Qualified P
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Employer Responsibilities (continue
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Preventing Shock • Safety Plannin
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Page 81 and 82: (c)(2) (c)(3) (c)(4) Communications
Page 83 and 84: (b)(3)(ii) The skills and technique
Page 85 and 86: The work practices that are used sh
Page 87 and 88: equivalent to that obtained by use
Page 89 and 90: Note: The work practices used by qu
Page 91 and 92: (c)(3)(iii)(B)(2) The equipment is
Page 94 and 95: OSHA Standards Interpretation and C
Page 96 and 97: [01/07/1992] Electrical safety rela
Page 98 and 99: guards and/or devices assure employ
Page 106 and 107: contradict the guidance provided in
Page 108 and 109: • Verification is provided by a s
Page 110 and 111: Question: Reply: Would interlocking
Page 113 and 114: The following document is reproduce
Page 116 and 117: WHY THIS LOCKOUT IMPLEMENTATION KIT
Page 118 and 119: LOCKOUT STANDARD CHRONOLOGY Februar
Page 120 and 121: 6. Industry sectors, such as constr
Page 122 and 123: f. Each element of this program wil
Page 124 and 125: h. Locks shall be attached to each
Page 126 and 127: Training records such as attendance
Page 128 and 129: (b) (c) (d) (e) (f) Machinery equip
Page 130 and 131: (iv) Prior to lockout device remova
Page 134 and 135: Form No.2 WRITTEN PROCEDURE ELEMENT
Page 136 and 137: Are alternate energy control method
Page 138 and 139: Is procedure adequate? ____________
Page 140 and 141: Is job procedure for removal being
Page 142 and 143: 11. Have attempts been made to cont
Page 144 and 145: Document No- 1 PLANNING FOR TRAININ
Page 146 and 147: 8. The retraining must reestablish
Page 148: appropriate, to determine whether e
Page 152: One Hour Safety Presentation The ma
Page 156: Elements of a Lockout/Tagout Progra
Page 160: Identify Different Personnel u Auth
Page 164: List & Identify all Sources Of Ener
Page 168: Procedures For Each Piece Of u Writ
Page 172: Training Affected & Other Employees
Page 176: Develop Procedures On How You Will
Page 180: Miscellaneous Items in Your Program
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Other Things To Consider u When do
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Elements of a Lockout/Tagout Progra
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Identify Different Personnel u Auth
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List & Identify all Sources Of Ener
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Procedures For Each Piece Of Equipm
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Training Affected & Other Employees
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Develop Procedures on how you will
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Miscellaneous Items in Your Program
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Other Things To Consider u When do
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If an energy isolating device is ca
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Student Handouts
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Training Of Authorized Employees. u
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Shift & Personnel Changes u How to
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Resources Available from the Divisi
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Saving You Time and Research Reques
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The CDC is always a good resource f
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http://www.fmcsa.dot.gov/safetyprog
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Lockout / Tagout - Ohio Bureau of Workers' Compensation

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