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Equipment Description/Common Name:

Location of Equipment:

Equipment-Specific LOTO Developed/revised By:

Rev. Date:

1. NOTIFICATION OF AFFECTED EMPLOYEES: Affected employees who use or work near the equipment have been notified that it is being shut down. In addition to this lockout procedure, the Authorized Employee must be aware of any additional safety requirements when dealing with this type of equipmentYesNo

This procedure is to be used for:

2. ALL SOURCES OF ENERGY HAVE BEEN IDENTIFIED aboveYesNo

SOURCES OF STORED ENERGY (including their location) are

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