Completion of the (Sample) Lockout/Tagout Record Sheet

DOE-STD-1030-96

of each tag. Block [14] documents the required position of each component to restore

it to an operable condition, sequence for restoration, authorization for removal of each

tag, tag removal and restoration of each component to operable condition, and

verification.

Block [15], the remarks section, provides space for amplification on any action required or

condition observed during placement, verification, or removal of tags (and locks, if

used). For example, if two-valve isolation cannot be achieved in a hazardous system,

or if verification cannot be performed because of high radiation, a statement in the

remarks section should document the affected component(s), the reason, and the

appropriate supervisory approval. Block [15] should also be used to identify (by

signature, initials, and position) the personnel performing specific lockout/tagout

actions, such as installing tags, verifying installation, removing tags, verifying

removal, or adding tags to an existing lockout/tagout record.

A-6