Lockout / Tagout - Ohio Bureau of Workers' Compensation
Lockout / Tagout - Ohio Bureau of Workers' Compensation
Lockout / Tagout - Ohio Bureau of Workers' Compensation
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Form No.2<br />
WRITTEN PROCEDURE ELEMENTS<br />
Name/number/identification <strong>of</strong> machine, process or equipment __________________________________<br />
______________________ _____________________ ____________________ __________________<br />
Type(s), magnitude(s) and hazard(s) <strong>of</strong> energy present. _______________________________________<br />
______________________ _____________________ ____________________ __________________<br />
Name(s) and/or Job title(s) <strong>of</strong> employee(s) authorized to lockout ________________________________<br />
______________________ _____________________ ____________________ __________________<br />
Type(s) and location(s) <strong>of</strong> energy isolating means ____________________________________________<br />
______________________ _____________________ ____________________ __________________<br />
Type(s) <strong>of</strong> stored energy and methods to dissipate or restrain __________________________________<br />
______________________ _____________________ ____________________ __________________<br />
Means/Methods selected (specify locks/additional measures) __________________________________<br />
______________________ _____________________ ____________________ __________________<br />
Specify tools, test/measuring or other devices used to ensure effectiveness <strong>of</strong> disconnect ____________<br />
______________________ _____________________ ____________________ __________________<br />
______________________ _____________________ ____________________ __________________<br />
At Time <strong>of</strong> Group <strong>Lockout</strong> specify Name(s) and Job Title(s) <strong>of</strong> employee(s) covered by group lockout____<br />
______________________ _____________________ ____________________ __________________<br />
______________________ _____________________ ____________________ __________________<br />
[Copies <strong>of</strong> Posted Procedures Shall Be Retained by the Local Joint Health and Safety Committee, and<br />
made available to employees upon request.]