Completion of the (Sample) Lockout/Tagout Record Sheet

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

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