Lockout/tagout machine-specific checkoff
The employee below completed the online portion of lockout/tagout training on LifeSafetyWiki. Cover Parts 1 and 2 on site on the machines they will service (or work around), then sign Part 3. OSHA requires the employer to certify training with the employee’s name and the dates.
Part 1 — Your site (filled in by the employer)
| Machines and written proceduresWhich equipment, and where the procedures are kept | |
|---|---|
| Energy sources on those machinesElectrical, hydraulic, pneumatic, gravity, thermal… | |
| Personal locks and tags issuedColour or ID standard on this site | |
| Group lockout methodLockbox or group device, who is in charge | |
| Shift change and absent-worker lock removalSite procedure per 1910.147(e)(3), (f)(4) | |
| RoleAuthorized, affected, or other employee |
Part 2 — Hands-on check (by the authorized employee who trains or supervises lockout)
| The employee showed they can | OK | Not yet |
|---|---|---|
| Identify every energy source and isolating device on the machine1910.147(d)(1) | ☐ | ☐ |
| Perform the shutdown, isolate and apply a personal lock and tag1910.147(d)(2)-(4) | ☐ | ☐ |
| Release or block stored energy1910.147(d)(5) | ☐ | ☐ |
| Verify isolation (try) and return controls to off1910.147(d)(6) | ☐ | ☐ |
| Use the group lockout device or lockbox1910.147(f)(3) | ☐ | ☐ |
| Release the machine: clear, notify, remove own lock1910.147(e) | ☐ | ☐ |
Part 3 — Certification
I certify that the employee named above received lockout/tagout training appropriate to their role on this site, including the machine-specific energy control procedures listed (29 CFR 1910.147(c)(7)(iv)).
OSHA requires a training certification with each employee’s name and the training dates, and an annual certified inspection of each procedure (1910.147(c)(6)). This form does not replace the employer’s own program, and LifeSafetyWiki does not certify competence. Not an OSHA Outreach (10/30-hour) card.