Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Select date
Pre-Use Equipment Inspection:
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Did Employee inspect the lift and all equipment ( i.e. Safety devices, air/hydraulic/fuel system for leaks, cable/wiring harness for damage, loose/missing parts, tires and wheels, placards/warning/control labels, outriggers/stabilizers, and other structures/guard rails, is platform work area free of tripping hazards) ?
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Work Area Inspection:
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Did the employee inspect the work area for pot holes, uneven ground, debris, floor obstructions, electrical hazards, proper ground for support of outriggers, wind and weather conditions, the presence of bystanders or any other physical hazards?
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Utilization of Fall Protection:
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Did employee demonstrate the proper use of three point contact when entering the unit and use proper fall detection devices in the proper manner?
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Function Test or Lower Control Station and Bucket/Platform:
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Did employee check control station and bucket/platform for malfunctions prior to use?
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Drive and Creep/Inch Forward and Reverse:
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Did employee move at least 10 feet in a driving mode and creep for at least 5 feet in a creeping mode while maintaining stability at all times?
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Turn Vehicle 360 Left and Right:
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Did employee make a complete 360 degree left and right turn with minimal disturbance of platform maintaining unit stability?
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Boom Up and Down/In and Out:
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Did employee fully extend boom or fully raise with minimal disturbance of the platform?
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Rotate/Swing Boom 360 Degrees In Each Direction:
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Did employee Rotate/Swing Boom 360 Degrees In Each Direction with minimal disturbance to platform maintaining unit stability?
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Tilt Platform In Each Direction:
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Did employee tilt the platform in each direction with minimal disturbance to the platform maintaining unit stability?
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Turn Off Unit Using Emergency Shutdown:
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Did employee locate and properly use the emergency shutdown switch to turn off unit?
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Park and Shut Off Aerial/Scissor Lift:
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Did the employee shut off the unit while maintaining unit stability at all times?
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Exiting The Unit Utilizing Three Point Contact Method?
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Did the employee Exit The Unit Utilizing Three Point Contact Method?
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Certification Statement and Signatures
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I certify that the above mentioned employee has successfully completed the above mentioned steps in the certification process. Also all information in this certification is true and accurate to the best of my knowledge.
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I certify that I have successfully completed the above mentioned steps in the certification process. Also all information in this certification is true and accurate to the best of my knowledge.
