ࡱ> :<9 bjbjWW (55hh-8-:-:-:-:-:-:-$/W2`^-^-s-  8- 8- n|+,", $--0-,D2 2@,2,< ^-^- -2h : Enter Company or Facility Name Authorized Employee LOCKOUT - TAGOUT (LOTO) Training Certificate Employee Name ________________________ Dept. ____________________________________ Printed I understand the training I have received on the mandatory Lockout Tag out program. The training consisted of: Location of equipment, control operation and energy isolation points. How to safely turn on and off equipment. Type(s) and hazard(s) of energy sources. Type(s) and magnitude of the energy. Facility machine specific methods and means necessary for energy isolation. I understand the hazards of electricity, hydraulic force and machines in motion. I understand that I have been trained to protect myself by not reaching into (breaking the plane) on any machinery until I have personally Locked and Tagged all sources of energy and ensured that the machinery controls have been disabled. I understand that if I chose to isolate a machine energy source by unplugging the power cord I must be in control of the plug at all time and that I may not leave the area until the machine is in a condition that would allow the machine to be safely plugged into a receptacle. I acknowledge receipt of necessary locks, hasps, tags, etc. required for effective isolation of electrical power to a single piece of equipment and that I have available (from supervisors) material needed for isolating hydraulic fluid flow to hydraulic motors. I understand that if I need additional LOTO material, I am accountable for requesting it from a supervisor in my department. I understand that VIOLATING THE LOCKOUT-TAGOUT PROCEDURE will result in disciplinary action up to and including termination of employment. Employee Signature ______________________________________ Date ________________ By signing below, the employer or designated employer representative, ensures the employee has met the purpose and function of the Lockout-Tagout energy control program. The employee demonstrated understanding, knowledge, and the skills required for safe application, usage, and removal of the energy controls. This authorizes the employee named above to perform Lockout/Tag Out. 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