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LOCKOUT TAGOUT POLICY AND PROCEDURES <br />livingcenters <br />Attachment "B" <br />ANNUAL LOCKOUT/TAGOUT REVIEW CHECKLIST <br />This checklist is designed so that an "Authorized Person" can evaluate the LOTTO program in the <br />facility. Please complete this checklist annually and maintain a copy for documentation purposes. <br />(Any answers marked "No", must be corrected immediately.) <br />1. Does the maintenance department have a copy of the facility LOTTO policy and <br />procedure including the Outside Contractor Checklist and Acknowledgement Yes_ No_ <br />form for Hazard Communication and LOTTO? <br />2. Does the maintenance department follow all the LO/TO procedures that are <br />listed in the facility LO/TO policy and the Safety & Loss Control Manual Yes_. No_ <br />beginning on page 3.23? <br />3. Are outside contractors required to sign the Contractor Acknowledgement <br />Form whenever their work involves hazardous chemicals or LO/TO? Yes_ No_ <br />4. Is the "LOTO Equipment Isolation Procedure Form" part of the facility LOTO <br />policy? Is the form used to document specific procedures for all equipment? Yes_ No_ <br />Have procedures for each piece of equipment been reviewed? <br />5. Have all "affected" employees been instructed in the safety significance of <br />LO/TO procedures and their duties and responsibilities for LOTO? Yes_ No_ <br />6. Are all affected employees contacted before LO/TO is implemented and when <br />the work is completed? Yes_ No_ <br />7. Review the inventory of lockout/tagout supplies: dedicated padlocks, valve <br />locks, circuit breaker locks and "Do Not Operate" tags. Is the inventory Yes_ No_ <br />complete? <br />8. Review all specific LOTTO procedures for securing & de -energizing <br />equipment. List any changes to procedures identified or any new equipment Yes. No— <br />that requires a specific LO/TO procedure: <br />Comments: <br />I certify that the lockout/tagout policy procedure for (Facility Name) has been <br />thoroughly reviewed using the above checklist. <br />Authorized Person Date <br />Title <br />Maintenance Supervisor Date <br />Golden Living LCJCKOUTITAGOUT Page 8 of 10 <br />