D&G Noble Ltd

• Name of Lift Supervisor

• Date and time of inspection

  Date

• Client

• Site Address

• Lift Plan

• Dynamic Risk Assessment

• Has the on site dynamic risk assessment been carried out and are all risks controlled?

  Yes

  No

• Lifting operation must be stopped. Lift Supervisor to contact the Appointed Person.

• Is the vacuum lifter attachment as detailed and configured as within this lift plan?

  Yes

  No

• Lifting operation must be stopped. Lorry Loader Operator to contact the Appointed Person.

• Does the 6-month Report of Thorough Examination match the vacuum lifter on site?

  Yes

  No

• Lifting Operation must be stopped. Lorry Loader Operator must contact the Appointed Person.

• Lifting Operation must be stopped. Lift Supervisor to contact the Appointed Person.

• Has the Vacuum Lifter Operator carried out a Pre-Use Check of the Vacuum Lifter? If yes take photo and attach here.

  Yes

  No

• Vacuum Lifter Operator must carry out pre-use inspection of vacuum lifter

• Toolbox Talk

Lift Team

• Lift Supervisor: I confirm that I have been fully briefed on the contents of this lift plan and that I accept the duty of ensuring that my role in the lift(s) will be carried out in accordance with the method and procedures set out in this document. I have the right to stop operations if I feel that even though the parameters of the lift plan are met, I feel it would be unsafe to continue. In which case the lifting operation will be stopped, and the AP will be contacted for further information.

  Sign

• Lorry Loader Operator: I confirm that I have been fully briefed on the contents of this lift plan and that I accept the duty of ensuring that my role in the lift(s) will be carried out in accordance with the method and procedures set out in this document. I have the right to stop operations if I feel that even though the parameters of the lift plan are met, I feel it would be unsafe to continue. In which case the lifting operation will be stopped, and the AP will be contacted for further information.

  Sign

• Slinger Signaller: I confirm that I have been fully briefed on the contents of this lift plan and that I accept the duty of ensuring that my role in the lift(s) will be carried out in accordance with the method and procedures set out in this document. I have the right to stop operations if I feel that even though the parameters of the lift plan are met, i feel it would be unsafe to continue. In which case the lifting operation will be stopped, and the AP will be contacted for further information.

  Sign

Other Personnel

• I can confirm I have been briefed on the contents of this lift plan and fully understand my responsibilities.

• Add signature

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