Title Page
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Site conducted
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Employee Name
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Employee Certificate Expiration (if applicable)
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Evaluator Name
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Evaluation Date
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Equipment make/model used during the evaluation
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Ferreira Eq Number
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Ferreira Dept. and Region Number (FCC Utility, FCC Traffic & Company Code 40,42,43,45)
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Task performed during evaluation
Evaluation Checklist
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Assembly / Disassembly Operations
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Setup for operations
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Cribbing/matting setup
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Leveling /Placement (daily verification)
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Adequately identified and avoided existing underground utilities
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Setup / positioned to reduce boom radius requirements
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Tail swing clearance verified
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Swing radius protection in place
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Fueling operations
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Pre-use inspection TENNA / HCSS
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Performed pre-lift testing and requirements for personnel basket use
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Demonstrated knowledge is weather affects of crane operation
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Safely mounted and dismounted crane
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Able to determine load weight
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Properly evaluated and utilized load chart / line capacity
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Demonstrate knowledge in rigging requirements
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Utilized a tag line on all lifts except where it presented additional hazards
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Positioned boom to the center of gravity of load
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Adjusted boom for deflection prior to lift
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Demonstrated knowledge in standard signals
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Ensure safe swing path is maintained during lift (obstructions/personnel)
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Operated the equipment within its operational limitations / maintained operational control
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Maintained safe operations
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Minimized dynamic loading operations
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Safely traveled crane with / without load
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Kept personnel from hazardous areas during operation
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Maintained adequate distance from electrical lines or had other required controls in place
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Loaded/Unloaded trucks using safe work practices
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Did not leave equipment unattended while loaded
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Performed dry run for critical lifts
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Performed PM / Grease maintenance as required
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Based on my evaluation the operator:
- is qualified for this level of operation on this type of machine
- is NOT qualified for this level of operation on this type of machine
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Evaluator Signature
