Company Name:

Lockout/Tagout Training Acknowledgment

I, , acknowledge receipt of training with regard to Control of Hazardous Energy Program and Lockout/Tagout Procedures. I understand the purpose for having such a plan is to reduce injuries resulting from the accidental startup of a machine or piece of equipment while undergoing service or routine maintenance. I have been instructed to identify the piece of machinery and/or equipment and its energy source utilizing the company's Survey For Applying Lockout/Tagout Devices prior to beginning any lockout/tagout procedures. I have been further instructed to fill out my own monthly Lockout/Tagout Time Schedule each time I begin lockout/tagout procedures; and to have my immediate Manager/Supervisor sign off on this form granting approval for continuing servicing or providing maintenance to the piece of equipment or machinery. I further understand that it is my responsibility to notify all co-workers of a machine or equipment’s inactive state each time I begin lockout/tagout procedures.

Training was received on this day of , Year

Employee's Signature Date

Trainer's Signature Date