SIMPLY GYM PLATE LOADED (UPPERBODY) - BLANK

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

CHEST PRESS

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

INCLINE CHEST PRESS

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

DECLINE CHEST PRESS

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

SEATED ROW 1

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

SEATED ROW 2

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

LAT PULLDOWN

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

SHOULDER PRESS

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

T-BAR ROW

• 1       Hinges move smoothly and do not squeak (oil if needed)

  Yes

  No

  N/A

• 2        Can all adjustments be moved safely

  Yes

  No

  N/A

• 3        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 4        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 5 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 6 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

ROMAN CHAIR

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

FLAT BENCH PRESS (LEFT)

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

FLAT BENCH PRESS 2

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

FLAT BENCH PRESS 3

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

FLAT BENCH PRESS 4 (RIGHT)

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

INCLINE BENCH PRESS 1 (LEFT)

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

INCLINE BENCH PRESS 2 (RIGHT)

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

DECLINE BENCH PRESS 1 (LEFT)

• 1        Are any bolts missing

  Select Compliant Non-Compliant N/A

  • Compliant
  • Non-Compliant
  • N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A

DECLINE BENCH PRESS 2

• 1        Are any bolts missing

  Compliant

  Non-Compliant

  N/A

• 2        Are all nuts and bolts tightened

  Yes

  No

  N/A

• 3 Condition of seats and pads

  Good

  Fair

  Poor

  N/A

• 4 How safe do you feel using this piece of equipment? 1 = Not Safe - 5 = Safe

• 5 Any sharp edges

  Safe

  At Risk

  N/A