Mobile Crane Qualified Operator Evaluation

• Conducted on

  Date

• Prepared by

• Location
  Address

• Operator Name

• Employee #

• Certification Issue by

• NCCCO #

• Crane Make

• Model

• Crane Type - Chose the correct crane type and configuration below:

• Boom Tucks - Fixed Cab (BTF)

• Photo of Crane

  Media

• Service Truck Cranes (STC)

• Photo of Crane

  Media

• Telescopic Boom Crane - Swing Cab (TLL)

• Photo of Crane

  Media

• Articulating Boom Crane (ABC)

• Photo of Crane

  Media

• Articulating Boom Crane with Winch (ABW)

• Photo of Crane

  Media

• What is the crane's lifting capacity? (in lbs)

• What is the boom length? (in feet)

• Are there any attachments?

  Yes

  No

• List attachments:

• undefined

Evaluation Section

• I have evaluated the operator on the following knowledge areas and have determined he/she is competent in these areas for the equipment which he/she will operate.

• Crane Operation

  Sign

• Operation Aids

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• Safety Devices

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• Software

  Sign

• Shutdown

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Evaluator Section

• I have evaluated the operator with respect to the equipment that he/she will operate and have determined that he/she:

• 1. Has the skills and knowledge, as well as the ability to recognize and avert risk, necessary to operate the aforementioned equipment safely, including those specific to the safety devices, operation aids, software, and the size and configuration of the equipment. [OSHA 1926.1427(f)(1)(i)]

  Sign

• 2. Understands and can apply the equipment's load charts as well as the manufacture's procedures.

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• Evaluator's Name

• Evaluator's Company Name

• Evaluator's Signature

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