Lockout / Tagout - Ohio Bureau of Workers' Compensation

11. Have attempts been made to contact employee at home? ___________Yes ______ No ________
Telephone number called ________________________________________________________________
Dates and times of call(s) ________________________________________________________________
Name(s) of person(s) spoken to ___________________________________________________________
12. Successful employee contact at (location) ______________________ (date) __________________
(time) ______________________________________
13. Employee advised that ______________________(Action taken to remove lock) ______________
______________________________________________________________________________________
14.Authorized employee representative (name) ______________________________________________
notified ________________________ (date) _____________________________ (time) ____________
15. Was machine, process or equipment reinspected prior to lockout device removal? _____________
Yes ___________No ___________
16. Name and title of person authorizing removing lockout device _______________________________
______________________________________________________________________________________
17. Was employee notified of removal prior to start of next scheduled shift ____Yes ______ No _____
If yes, by whom? (name) _________________________________________________________________
Date and Time of Issuance _______________________________________________________________
Signature of Management Representative __________________________________________________
Print Name in Full _______________________________________________________________________
Signature of employee's immediate supervisor _______________________________________________
Print Name in Full _______________________________________________________________________
(THIS FORM IS TO BE RETAINED FOR ONE YEAR FROM THE DATE OF ISSUANCE BY ________
____________________________________________________________________________ (name of
responsible management representative)).