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Lockout / Tagout - Ohio Bureau of Workers' Compensation

Lockout / Tagout - Ohio Bureau of Workers' Compensation

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<strong>Lockout</strong>/<strong>Tagout</strong><br />

Energy Source Identification<br />

Machine:<br />

Location:<br />

Person Identifying Sources:<br />

Date:<br />

Dept.:<br />

TYPE OF ENERGY<br />

ELECTRICAL<br />

HYDRAULIC<br />

PNEUMATIC (AIR)<br />

CHEMICAL<br />

THERMAL<br />

MECHANICAL<br />

CORD & PLUG<br />

CONNECTED<br />

OTHER<br />

YES NO<br />

METHOD, DEVICE OR SYSTEM<br />

SELECTED TO DE-ENERGIZE,<br />

POWER SOURCE (Voltage, Pressure, etc.)<br />

_______________________________________________________________________<br />

2-17

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