Safety Competency Record

Date

Time

Equipment Type

Completed

Defective Tools

Fire Extinguishers

Fueling Equipment

Moving Equipment

Excavation and Ground Disturbance

Powered Mobile Equipment

Work Near Overhead Power Lines

Hazardous Energy Control

Backing Up Mobile Equipment

Boosting Equipment

Equipment Startup/Shutdown

Starting Equipment

Getting On/Off Equipment

Loading Equipment

Loading Gravel Trucks

Ripping Frost

Spill Procedure in Creek or Valley

Spill Procedure on Land

Fuel/Oil/Lubricant

Unloading Equipment

Washing Equipment

Limitations of Movement/Use

Safety Features and Equipment Load Ratings

Familiar with Attachments

Operator Understands and Demonstrates the Proper Completion of the AM/PM Checklist

Operator Understands the Procedure for Reporting Defects Needing Repair (Lockout/Tagout)

Operator Understands Their Rights Under the Company Health and Safety Policies and Applicable Occupational Health and Safety Code

Worker has Been Deemed Competent by Demonstrating the Ability to Safely Perform Work with Minimal or No Direct Supervision

Operator

Operator Signature

Safety Manager

Safety Manager Signature

Foreman

Foreman Signature

Supervisor

Supervisor Signature