Equipment Operator Certification Card Template Details

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QuestionAnswer
Form NameLiftap
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslift certification card template, scissor lift training card, aerial lift certification card template pdf, printable aerial lift certification card template

Form Preview Example

Monterey Mechanical Co.

Contra Costa Metal Fabricators - Pacific Metal Fabricators - Monterey Metal Fabricators

EQUIPMENT OPERATOR EVALUATION FORM

New: 3/28/2011 Revised:

Operator name:

________________________________________

Operators latest training date:

_______________

Source of training:____________________________________

Type of equipment evaluated on:

Conventional(FL) Rough Terrain(FL)

Boom Lift(AP) Scissor Lift(AP)

Evaluation type:

 

Initial

Re-evaluation

 

Circle a “Y” if the employee passes or an “N” if the employee does not perform the task properly. Any circled “N” requires that the employee be re-instructed in the areas of concern and evaluated again if needed. This re-evaluation shall be indicated as being performed in the comments box. Only then can a “Pass” be achieved.

VISUAL CHECKS

 

 

 

 

 

Both

Wheels, tires

Y N

 

Both

Keeps clear view of path while traveling

Y N

Both

Fluid leaks

Y N

 

Both

Yields to pedestrians

Y N

Both

Guards, guardrails(AP) and covers

Y N

 

Both

Keeps body inside of unit

Y N

Both

Items not stored on equipment

Y N

 

Both

Is aware of all clearances

Y N

Both

Capacity plates, load decals

Y N

 

Both

Maintains control at all times

Y N

Both

Can they locate the vehicle manual

Y N

 

Both

Operates in designated areas

Y N

Both

Able to locate inspection tag

Y N

 

Both

Avoids bumping and pushing

Y N

FL

Forks, carriage, mast

Y N

 

Both

Unit parked correctly

Y N

AP

Anchor points for fall protection

Y N

 

FL

Uses seatbelt

Y N

 

 

 

 

FL

Understands load chart

Y N

 

 

 

 

FL

Approaches and lifts loads correctly

Y N

OPERATOR CHECKS

 

 

FL

Loads properly placed on the forks

Y N

Both

Lifting mechanism

Y N

 

FL

Checks load before lifting for being secure

Y N

Both

Brakes and steering

Y N

 

FL

Checks behind before putting into reverse

Y N

FL

Instrument gauges

Y N

 

FL

Travels with the forks at a safe level

Y N

FL

Backup alarm, horn, seatbelt, lights

Y N

 

FL

Sounds horn when needed

Y N

AP

Travel alarm

Y N

 

FL

Places and pulls out of load correctly

Y N

BASIC OPERATION

 

 

AP

Checks 360degrees for clearance prior to movement

Y N

Both

Uses 3 points of contact for access

Y N

 

AP

Closes gate or chain

Y N

Both

Competent operation of controls

Y N

 

AP

Checks for overhead clearances when raising

Y N

Both

Travels at a safe speed

Y N

 

 

 

 

Comments:

* If fall protection is used the user must be trained in the use of fall protection.

Employee:

Pass

Fail

Employee Initials:___________________

Evaluators name (print):

______________________________________

Evaluator signature:

_________________________________________ Date: _______________

Return the completed form to the Safety Department