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Specific Instructions for Hazardous Machinery

Part I
Machine Name:_________________________________________________________________________
Machine Serial Number:___________________________________________________________________
Department Name:_______________________________________________________________________
Approved by:____________________________________________ Date:__________________________

Part II
a. What types of hazardous energy may be present?
Circle all that apply.

    Electrical   Chemical   Pneumatic   Hydraulic   Thermal   Other: ____________________

b. Complete Energy Check List (Reverse side of this form)

c. Special Locking and Tagging instructions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Part III
Attach a diagram or photo identifying lock and tag locations:

 

                                                              Energy Control Diagram                                                                           

Energy Checklist

Energy TypeHazardMagnitudeControl Method
ElectricalShock
Burn
Fire
___________		110 VAC
220 VAC
208 VAC/30
___V____A		Main Switch
Plug Control
Fuse Blocks
Shielding
PneumaticMechanical/
Pinch Points
Crush
Laceration
Flying Debris		Moderate
Slight
High
___lb Force		Air Line Valve
Gas Cylinder Valve
Gas Line Valve
___________
Chemical
(Gas)		Flammable
Corrosive
Toxic
Reactive		Slight
Moderate
High		Cylinder Valve
Gas Line Valve
Chemical
(Liquid)		Flammable
Corrosive
Toxic
Reactive		Slight
Moderate
High		Valve
Flange Plate
MechanicalShaft in Motion
Moving Parts
Crushing
Laceration
Impalement		Slight
Moderate
High
____ft-lb
____hp		Main Electrical
   Switch
Plug Control
Shielding
Blocking
Anti-Motion Pin
UVSkin and Eye
Burns		Slight
Moderate
High
___W/cm²@___%		Shielding
Main Switch
Plug Control
Circuit Breaker
ElectroMagnetStrong FieldSlight
Moderate
High
____Gauss		Main Switch
Plug Control
Circuit Breaker
ThermalBurnsModerate
 Temperature
High
 Temperature
Cryogenic
____°C		Main Switch
Plug Control
Steam Valve
Fluid Line Valve

*Chart adopted from the January/February 1995 issue of Compliance Magazine.

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