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DOE-STD-1030-96
Completion of the (Sample) Lockout/Tagout Record Sheet
Lines [1], [2], and [3] request administrative information to identify the lockout/tagout, the
equipment affected, and the name of the requester.
Line [4] requires determination of any independent verification requirement at the time the
lockout/tagout is applied. Independent verification may be required on some systems,
particularly safety systems, following installation of a lockout/tagout to ensure that
required safety functions have not been inadvertently affected. Additional information
concerning independent verification requirements can be found in DOE Guide to Good
Practices for Independent Verification.
Line [5] requires identification of safety-related testing requirements, in accordance with
facility safety standards.
Line [6] confirms the proper listing of tagout points (Block [12]) and preparation of tags,
and documents approval by the responsible supervisor or manager to begin installing
the lockout/tagout.
Block [7] provides space to identify the work activity(ies) requiring protection under this
lockout/tagout. Activities may be identified by their work control document number,
procedure number, etc.
Block [8] provides space for appropriate lockout/tagout holders (individuals or
representatives of work groups) to document their acceptance of the lockout/tagout as
adequate protection for their intended work.
Block [9] provides space for the responsible supervisor or manager to document that the
lockout/tagout has been properly installed and that work is authorized to begin for each
individual, work group, or shift.
Block [10] provides space for these individuals or work group representatives to document
their release of the lockout/tagout at the end of the job (or shift).
Block [11] provides for the responsible supervisor or manager to document the closure of
the lockout/tagout after it has been released by all users (Block [10]) and has been
removed and restored to operational condition (Block [14]). If post-maintenance
testing is required to prove operability, it should be identified in Block [11].
Blocks [12], [13], and [14] document the preparation, placement, and removal of each
individual tag. Block [12] provides space to list components that will form isolation
boundaries around or verification points within the work area, the required position of
each component, and the sequence in which the tags should be placed. The authorized
persons who prepare the list and tags and who verify the accuracy and adequacy of the
protection should be identified in the spaces labeled "Prepared by" and "Verified by."
Block [13] documents the positioning of components and the placement and verification
A-5


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