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Page Title:
(Sample) Lockout/Tagout Record Sheet |
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|  DOE-STD-1030-96
LOCKOUT/TAGOUT RECORD SHEET
[1] Lockout/Tagout Number
-
-
Facility - Year-Number
[2] Component/System:
[3] Requested By:
[4] Independent Verification Required at Lockout/Tagout
Yes
No
[5] Safety-Related Testing Required
Yes
No
Specify testing conducted:
[6] Lock/Tag Preparation (Block [12]) completed; Placement of Locks/Tags Authorized
(Operations Supervisor)
[7]
[8]
[9]
[10]
Issued For
Accepted
Work Authorized
Release
(Lockout/Tagout Holder)
(Responsible Supervisor)
Lockout/Tagout
(Lockout/Tagout Holder)
Activity
Name
Date/
Name
Date/
Name
Date/
Identification
Time
Time
Time
Blocks [7], [8], [9], & [10] continued on additional sheets?
Yes
Restoration (Block [14]) Completed / Operability Checks Satisfactory
[11]
Specify testing performed:
(Responsible Supervisor or Manager)
A-3
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