007 - LockOut-TagOut Periodic Inspection Form.pdf
PDF 137 KB Posted
- Solicitation number
- N4008524R2666
About this file
This document is a Lock-Out/Tag-Out Periodic Inspection Form used to document an inspection of a written lockout or tagout procedure. The form includes a checklist to verify that authorized employees know the location of the written procedure, have access to it, and have been trained on its use. It also checks whether affected employees are notified when the procedure is being used and have been trained. The form documents the inspection date, the list of authorized employees using the procedure, and any deficiencies requiring corrective action.
The related federal contract opportunity is a solicitation from the Department of the Navy Naval Facilities Engineering Command for the removal and proper disposal of Zebra Mussels and marine deposits attached to the active Raw Water Intake (RWI) and associated timber crib structure. The contractor will be required to furnish all labor, tools, transportation, supervision, materials, inspections, equipment, and safety compliance necessary to ensure unrestricted water flow to the Great Lakes Water Treatment Plant.
View the file
Other files
Show all 22
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Equipment type and serial number:
Lock-Out/Tag-Out Periodic Inspection Form
Note to employers: Use this form to document an inspection of a written lockout or tagout procedure.
Contractor:
Contract Number: N40085-XX-X-XXXX
Inspection conducted by:
Equipment location:
Employee name: Yes No
Employee name: Yes No
Employee name: Yes No
Employee name: Yes No
Do authorized employees know the location of the written procedure? Yes No
Do authorized employees have access to the procedure? Yes No
Are affected employees notified when the procedure is being used? Yes No
Have affected employees been trained to recognize when the procedure is being used and instructed not to remove lockout/tagout devices or start de-energized equipment?
Yes No
Can energy-isolating devices be locked out?
Note: When you replace, renovate, or modify machines and equipment, ensure that the energy-isolating devices will accept lockout devices. New equipment and equipment renovated or modified after January 2, 1990, must be capable of being locked out.
Yes No
Did each authorized employee lock out all energy sources? Yes No
Does this procedure involve group lockout/tagout? Yes No
Did the authorized employees verify that the equipment was de-energized? Yes No
Did the authorized employees follow the lockout/tagout procedure? Yes No
Does the lockout/tagout procedure adequately protect employees? Yes No
List of authorized emplyees using this procedure. Has the employee been trained in the procedure?
Inpection date:
If not, list and describe the deficiencies requiring corrective action.
1.
2.
3.
4.
5.
If this is a lockout procedure, did the inspector review with all authorized and affected employees their responsibilities under the procedure? Note: A review can be accomplished by meeting with employees individually or in a group.
Yes No
Not applicable
If this is a tagout procedure, did the inspector review with all authorized and affected employees their responsibilities under the procedure? Note: A review can be accomplished by meeting with employees individually or in a group.
Yes No
Not applicable
File details come from the government source that posted it. Updated .