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Lockout/tagout periodic inspection form.
A printable annual inspection and certification form for each energy control procedure, built on the four fields OSHA 1910.147(c)(6)(ii) requires. Free, no signup. Print it or save it as a PDF.
Quick answer. OSHA 1910.147(c)(6) requires an inspection of every energy control procedure at least once a year, carried out by an authorized employee who does not use that procedure. The employer must certify it, and the certification has to name four things: the machine or equipment, the date, the employees included, and the person who performed the inspection.
Reviewed October 16, 2026 against the regulation text on osha.gov. Not legal advice: your AHJ, insurer or the manufacturer can require more.
The form
Blank form below. Print it, or choose “Save as PDF” in the print dialog.
Energy control procedure: annual periodic inspection and certification
| Check | Yes | No | N/A |
|---|---|---|---|
| The written procedure is current and specific to this machine or equipment | |||
| The inspector does not use this procedure | |||
| An authorized employee was observed applying the procedure step by step | |||
| Every energy source named in the procedure was isolated | |||
| A lock or tag was applied to each energy-isolating device | |||
| Stored or residual energy was relieved, disconnected or restrained | |||
| Isolation was verified before work began | |||
| Lockout: each authorized employee's responsibilities were reviewed with them | |||
| Tagout: responsibilities and tag limitations were reviewed with each authorized and affected employee | |||
| Any deviation or inadequacy found has been corrected (details below) |
| Name | Authorized or affected | Responsibilities reviewed (initials) | Notes |
|---|---|---|---|
Certification under 29 CFR 1910.147(c)(6)(ii). Keep with the energy control procedure. Template from hovermarks.com.
What the regulation says
“The employer shall conduct a periodic inspection of the energy control procedure at least annually to ensure that the procedure and the requirements of this standard are being followed.”
“The periodic inspection shall be performed by an authorized employee other than the one(s) utilizing the energy control procedure being inspected.”
“The periodic inspection shall be conducted to correct any deviations or inadequacies identified.”
“The employer shall certify that the periodic inspections have been performed. The certification shall identify the machine or equipment on which the energy control procedure was being utilized, the date of the inspection, the employees included in the inspection, and the person performing the inspection.”
What the certification must show
The certification is the record an OSHA compliance officer asks for. A procedure that was inspected but never certified looks the same, on paper, as one that was never inspected. The form below carries the four required fields at the top, so a completed sheet always satisfies (c)(6)(ii) even if the checklist underneath is left short.
- The machine or equipment on which the procedure was being used
- The date of the inspection
- The employees included in the inspection
- The person who performed the inspection
Who can do the inspection
An authorized employee, meaning someone trained to lock or tag out machines, who is not one of the people using the procedure being inspected. In practice that is often a maintenance lead from another area, or a safety coordinator who is also an authorized employee. A supervisor who is not an authorized employee does not qualify on that basis alone.
The inspection is meant to catch drift: steps skipped, energy sources missed, locks applied to the wrong point. If the inspector finds a deviation or a gap in the procedure, (c)(6)(i)(B) requires it to be corrected, and the form gives space to record what was found and what was done.
Lockout and tagout reviews differ
Where the procedure uses lockout, the inspector reviews each authorized employee's responsibilities under the procedure with that employee. Where it uses tagout, the review covers each authorized and affected employee, and also the limitations of tags listed in 1910.147(c)(7)(ii). The employee table on the form has a column for each person's role so both cases are recorded.
Frequently asked
- How often must lockout/tagout procedures be inspected?
- At least once a year for each energy control procedure, under OSHA 1910.147(c)(6)(i). Many sites inspect more often for high-risk or frequently used procedures, but annual is the minimum.
- What must a LOTO periodic inspection certification include?
- Four items under 1910.147(c)(6)(ii): the machine or equipment on which the energy control procedure was being used, the date of the inspection, the employees included in the inspection, and the person who performed it.
- Who is allowed to perform the periodic inspection?
- An authorized employee other than the one or ones using the energy control procedure being inspected, under 1910.147(c)(6)(i)(A).
- Does one inspection cover every machine that shares a procedure?
- The inspection is of the procedure, but the certification must still identify the machine or equipment on which the procedure was being used when it was inspected. Record the specific machine you observed, not just the procedure number.
- Is this form a substitute for a written energy control program?
- No. 1910.147 also requires written procedures, training and the energy control program itself. This form records the annual inspection of one procedure. Confirm your obligations with your safety professional or OSHA consultation service.
Skip the paper
Hovermarks puts each machine's energy control procedure on a QR-tagged record. The annual inspection runs on a phone with the four certification fields built in, an overdue procedure shows up before the anniversary, and the certification history stays with the machine.
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