QXR02

• Unique ID or inspection #

• Client

• Client location

• Equipment location

• Conducted on

  Date

• Inspected by

• Inspection type

  Select

• Photo of Equipment Inspected

  Media

• Photo of Equipment Tags

  Media

Equipment Info:

• Equipment Manufacturer:

• Manufacture Date:

  Date

• Equipment Model #

• Equipment Serial #

General Inspection:

• Overall Condition?

  Good

  Fair

  Poor

  N/A

• Damage to Cover, Case or Structural Parts?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• Condition of Wheels?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• All Brakes and Stops Work?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• All Bolts In Place and Tight?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• All Welds Observed In Good Condition?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• All Moveable Parts Move Freely?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• All Operational Controls Functional?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

• Any Leaking Grease, Oil or Fluids Observed?

  Pass

  Fail

  N/A

• Reason for failure

  Select Cracks Loose Broken Siezed Missing Leaks N/A

  • Cracks
  • Loose
  • Broken
  • Siezed
  • Missing
  • Leaks
  • N/A

Specific Condition: Provide Photo and Comments for any "No" Answer

• Free of Damaged or Worn Parts?

  Yes

  No

  N/A

• Free of Broken or Bent Parts?

  Yes

  No

  N/A

• Free of any Sharp Edges?

  Yes

  No

  N/A

• Free of Burrs?

  Yes

  No

  N/A

• Free of Cracks?

  Yes

  No

  N/A

• Free Corrosion?

  Yes

  No

  N/A

• Parts free of distortion and elongation?

  Yes

  No

  N/A

Lifting or Hoisting Device:

• Type of Lifting or Hoisting Product

  Select Chain Wire Rope Synthetic Rope Synthetic Webbing Other (Photo and Describe in Comments)

  • Chain
  • Wire Rope
  • Synthetic Rope
  • Synthetic Webbing
  • Other (Photo and Describe in Comments)

• Do All Hooks Have Safety Latches?

  Yes

  No

  N/A

• Is the Product Free of Nicks, Cuts, Scratches and Similar Damage?

  Yes

  No

  N/A

• Free of Broken Fibers or Strands?

  Yes

  No

  N/A

• Free of Bent, Stretched, or Damaged Links ?

  Yes

  No

  N/A

• Free of Damage to Connectors, Crimps, or Sewn Terminations?

  Yes

  No

  N/A

• Free of Excessive Dirt or Abrasive Material?

  Yes

  No

  N/A

• Free of Burns or Heat Damage?

  Yes

  No

  N/A

• Free of Corrosion?

  Yes

  No

  N/A

Overall inspection Info:

• IF INSPECTION REVEALS ANY DEFECTIVE CONDITION, REMOVE FROM SERVICE.

• Disposition

  Select

• Signature of Inspector

  Sign