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Lockout / Tagout - Ohio Bureau of Workers' Compensation

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APPENDIX E<br />

ENERGY SOURCE EVALUATION<br />

DATE: _____/____/_____<br />

CONDUCTED BY: ___________________________<br />

In order to determine all energy sources for each piece or type <strong>of</strong> machine or<br />

equipment, fill in the following table.<br />

Location: _____________________ Work Center: ___________________________<br />

Equipment Name: _____________________________________________________<br />

Model: __________________________ Serial #: ____________________________<br />

<strong>Lockout</strong> Procedure Number: ____________________________________________<br />

ENERGY SOURCE \<br />

* MAGNITUDE<br />

LOCATION OF ISOLATING<br />

DEVICE<br />

MEANS OF<br />

ISOLATION<br />

ELECTRICAL<br />

ENGINE<br />

SPRING<br />

COUNTER WEIGHT<br />

FLYWHEEL<br />

HYDRAULIC<br />

PNEUMATIC<br />

CHEMICAL<br />

THERMAL<br />

OTHER<br />

_____________________<br />

* MAGNITUDE EXAMPLE - Electrical = 480v three phase<br />

Pneumatic = 125 p.s.i.<br />

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