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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:
________________________________________________________________________
________________________________________________________________________
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Part III
Attach a diagram or photo identifying lock and tag locations:
|
Energy Control Diagram |
| Energy Type | Hazard | Magnitude | Control Method |
| Electrical | Shock Burn Fire ___________ | 110 VAC 220 VAC 208 VAC/30 ___V____A | Main Switch Plug Control Fuse Blocks Shielding |
| Pneumatic | Mechanical/ 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 |
| Mechanical | Shaft in Motion Moving Parts Crushing Laceration Impalement | Slight Moderate High ____ft-lb ____hp | Main Electrical Switch Plug Control Shielding Blocking Anti-Motion Pin |
| UV | Skin and Eye Burns | Slight Moderate High ___W/cm²@___% | Shielding Main Switch Plug Control Circuit Breaker |
| ElectroMagnet | Strong Field | Slight Moderate High ____Gauss | Main Switch Plug Control Circuit Breaker |
| Thermal | Burns | Moderate 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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