Contractor_OSHA_LOTA_Notification_Acknowledgement_Record_Form_(15_Dec_14).doc

CONTRACTOR CONTROL of HAZARDOUS ENERGY (LOCKOUT/TAGOUT)

NOTIFICATION/ACKNOWEDGEMENT RECORD

(Training Acknowledgement Form)

Company Name: _____________________________________________________________________________________________ Type of Business: ____________________________________________________________________________________________ I hereby acknowledge fundamental understanding of Lockout/Tagout procedures as referenced in OSHA standard 29 CFR 1910.147 as related to my contracted work at Watervliet Arsenal. I acknowledge that I have provided training to my employees, as it pertains to the use of the Lockout/Tagout procedures on this project. It is responsibility of the contractor to provide proof of training and retention of training files.

· “Authorized Employees” have received training on the recognition of applicable hazardous energy sources, the type and magnitude of the energy available in the workplace, and the methods and means necessary for energy isolation and control [29 CFR 1910.147(c)(7)(i)(A)].

· “Affected Employees” have received training on the purpose and use of the energy control procedure [29 CFR 1910.147(c)(7)(i)(B)].

· “Other Employees” (those whose work activities are or may be in an area where energy control procedures may be utilized) have been instructed about the procedure and about the prohibition relating to attempts to restart or reenergize machines or equipment that are locked out or tagged out [29 CFR 1910.147(c)(7)(i)(C)].

I acknowledge that all OSHA Lockout/Tagout procedures will be followed and coordinate with the Watervliet Arsenal staff during this project.

Company Officer (Print Name):_________________________________________________________________________________ Title:_______________________________________________________________________________________________________ Signature/Date: __________________________________________________________________

WVA Safety Office (print name):_______________________________________________________________________________ Title:_______________________________________________________________________________________________________ Signature/ Date: ________________________________________________________________________

(WVA Safety Office) Note: All contract employees performing work at the Watervliet Arsenal shall be required to submit an acknowledgement of OSHA Lockout/Tagout training.