Operator’s Name: __________________________________ Date: __________________

Operator’s Manager: __________________________________ Pass (circle one): ​Yes No

Fall Protection Pass Fail Comments

Properly inspects harness, lanyard and shock absorber

Properly dons fall arrest PPE, checks for snug fit

Wears and uses appropriate PPE (glasses, boots, hard hat,

etc.)

Work Area Protection Pass Fail Comments

Checks ground surfaces: solid, level, and ready to support
truck

Checks ground surfaces: all trip hazards removed in area

Ensures no overhead obstructions

Clears area of workers by barricading, taping off, or notifying

Vehicle Setup Pass Fail Comments

Positions vehicle to operate safely (approach, reach,
obstructions)

Establishes safe working zone around vehicle

Visual & Operational Inspection Pass Fail Comments

Uses company inspection form

Completes Visual Inspection

Completes Operational Inspection

Training that takes you from consistently good to consistently great 1

 Task Performance Pass Fail Comments

Operates controls appropriately and with confidence

Maintains safe working distance from live power

Does not perform unsafe acts with equipment

Looks for hazards before moving boom/bucket

Maintains safe distances from obstructions

Operates equipment with smooth actions and at a safe

speed

Recognizes bucket weight capacity; does not overload

Does not overextend reach or climb out of bucket

Safety Precautions Pass Fail Comments

Climbs ladder or onto vehicle safely using three-point
contact

Enters bucket safely

Inspects anchor point before connecting lanyard

Ensures established working zone is safe before moving

bucket

Corrects any hazardous conditions prior to, or during work

Evaluator’s Name: _____________________________ Evaluator’s Signature: _____________________________

Operator’s Name: _____________________________ Operator’s Signature: _____________________________

End of Document

Training that takes you from consistently good to consistently great 2