Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Has the work area been cleaned up and trash removed from the building? *

Yes

No

Has all equipment and tools been removed from the building/work area? *

Yes

No

Has all of the plastic been removed from the equipment? *

Yes

No

Has all LOTO locks been removed? *

Yes

No

Has the disconnect been tagged with a "pink" tag? *

IF YES, PLEASE INDICATE THE NUMBER OF TAGS BELOW

Yes

No

Has all tape on doors been removed and thrown away in the trash? *

Yes

No

Have all doors been returned to the way they were when you got here? *

Yes

No