Emergency Lock Removal Form

This form must be completed prior to the employee’s lock being removed.

APPENDIX A
EMERGENCY LOCK REMOVAL FORM	Entry
Name of employee who applied lock:
I.D.#
Job Title:
Dept.
Type of energy isolation used:
Date applied:
Reason for Lockout/Blockout
Reason for emergency lock removal:
Describe all reasonable attempts to contact employee:
Certification that employee could not be located:
Supervisor’s name:
Date & time:
Review of equipment/machine/process to ensure safe Lockout/Blockout device removal.
No employee exposures
No electrical exposures
Guards in place
No open pipe exposures
Review conducted by:
Authorized employee
Job title
Date & time
Certification that authorization was received before the employee’s Lockout/Blockout device was removed:
Department Manager
Date & time

APPENDIX A

EMERGENCY LOCK REMOVAL FORM


EMERGENCY LOCK REMOVAL FORM	Entry
Employee authorized to remove Lockout/Blockout device:
Was the employee contacted prior to resuming work at the facility?
Employee statement concerning failure to remove device:
Employee’s signature:
Supervisory action to prevent recurrence:
Form completed by:
Name:
Title:
Date:
Reviewed by:
Name:
Title:
Date:

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