Information
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Conducted on
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Prepared by
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Company Name
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Employee being evaluated
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Location
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EQUIPMENT INFORMATION
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Make and Model Specific (if more than one lift please list all equipment)
PRE-USE INSPECTION
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Follow the Operator's Daily Checklist
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Look for damage
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Including but not limited to: safety devices, air/hydraulic/fuel system for leaks, cable/wiring harnesses for damage, loose/missing parts, tires and wheels, placards/warnings/and control markings, outriggers/stabilizers and other structures, guardrail system, other items as specified in owner’s manual.
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Document all findings on checklist
SURVEY/INSPECT WORKSITE
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Including but not limited to: drop-offs or holes, slopes, bumps and floor obstructions, debris, overhead obstructions and electrical hazards, inadequate surface and support to withstand all load forces, wind and weather conditions, presence of bystanders, other unsafe conditions.
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Verify appropriate wind and weather conditions
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Checks for overhead obstructions and electrical hazards
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Checks for ground level obstructions and debris
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Checks for bystanders
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Checks for any other unsafe conditions
LOWER CONTROL STATION TEST
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Completed a proper function test to determine any malfunctions
SAFE ACCESS TO PLATFORM
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Face the machine and maintains 3 points of contact while entering
USE OF FALL PROTECTION EQUIPMENT
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Properly put on all correct fall protection
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Promptly and properly tied off to equipment upon platform access
PLATFORM CONTROL STATION TEST
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Completed proper function test to determine any malfunctions
SAFE TRAVEL: DRIVE AND CREEP "INCH: FORWARD AND REVERSE"
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Move approximately 10 feet in a driving mode. Creep approximately 5 feet. Verify unit balance and stability.
TURN LIFT 360 DEGREES IN EACH DIRECTION
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Minimum disturbance of lift platform. Verify unit balance and stability.
ELEVATE PLATFORM TO WORKING HEIGHT
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Safe operation including but not limited to: Check to clear nearby personnel, overhead obstructions and electrical hazards
SHUT DOWN MACHINE USING EMERGENCY STOP FUNCTION
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Locate and use emergency stop function
PARK AND SHUTDOWN MACHINE
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Park in safe and stable area
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Properly shut off operator's panel
SAFE DISMOUNT FROM LIFT
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Face the machine and maintains 3 points of contact while exiting
FINAL SHUTDOWN OF MACHINE
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Locate and activate "Dead Man or Kill Switch" to shut lift down completely
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Promptly and properly untie from equipment when exiting platform
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Based on my evaluation, the operator has ______________________ completed the evaluations and hands-on training.
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Evaluator Signature
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Employee being evaluated Signature
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Employee being evaluated Photo
