Lock Out Tag Out

Lock Out Tag Out

Date*

Time*

Location*

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Specific Room Location (Corridor/Room #, etc.)*

Purpose of Lockout*

File Upload for Lockout Procedure

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Lockout Procedure ID

Lockout Placed by (First/Last Name)*

Trade/Contractor Initiating (Check all that apply)*

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Energy Type(s) (Check all that apply)*

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Tag/Lock #*

Lockout Point ID 1

Lockout Point ID 2

Voltage/Pressure

Systems/Occupancies Affected

Personal Phone #*

Estimated Lockout Duration*

Supervisor (First/Last Name)*

Occupant Notification Submitted (Yes/No)*

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