QXR03

• Client

• Client location

• Equipment Location

• Unique ID or Inspection #

• Inspection type

  Lanyard

  Sling

  Self Retracting Lanyard (SRL)

  Anchor

• Conducted on

  Date

• Inspected by

• Photo of equipment inspected

  Media

• Photo of equipment tags

  Media

Equipment Info:

• Equipment date of manufacture:

  Date

• Previous inspection date:

  Date

• Equipment manufacturer:

  Select

• Equipment model #

• Equipment serial #

• Please select Inspection Type

  Lanyard

  Sling

  Self Retracting Lanyard (SRL)

  Anchor

• Label attached to harness and fully legible?

  Select

• Reason for failure

  Select

• Single Leg or Double Leg Lanyard?

  Select

• Is the Webbing in a Satisfactory Condition?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Is the Stitching in a Satisfactory Condition?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Are the Buckles in a Satisfactory Condition? (free from deformation, sharp edges, corrosion, cracks, rips, tears)

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Are the Connectors in a Satisfactory Condition?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Is the Shock Absorbing Pack in a Satisfactory Condition?

  Pass

  Fail

  N/A

• Is the label attached and fully legible?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Type of Sling?

  Select

• Effective Working Length (Feet)

• Is the outer sheath free from cuts, tears, discoloration, heat damage and are the core fibers encased?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Is the stitching in a suitable condition? (missing, Incomplete, Damaged or Frayed?)

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Single Leg or Double Leg?

  Date

• Cable Type

  Wire Rope

  Synthetic Webbing

  Synthetic Rope

  Anchor

• Effective working length?

• Is the fall indicator tripped (if present)

  Pass

  Fail

  N/A

• Are all components in place and free from damage?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Is the external casing free from cracks, dents, heat damage, and fall incidents?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Is the internal mechanism working effectively? (attachments point swivel, connectors working, cable brake effective, cable out/in)

  Pass

  Fail

  N/A

• Is the cable or webbing free from kinks, distortion, corrosion, burns, abrasion, cuts or breaks?

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Is there a service date stamp present and is this within date?

  Pass

  Fail

  N/A

• Anchor Type

  Select

• Size (length, diameter, beam size, etc.)

• Hardware and connectors in serviceable condition

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Sling or wire rope parts serviceable (if applicable)

  Pass

  Fail

  N/A

• Reason for failure

  Select

• Body or load bearing assemblies serviceable

  Pass

  Fail

  N/A

• Reason for failure

  Select

Summary

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

• Disposition

  Select

• Signed

  Sign