Name:

Address:

Postal Code:

Telephone Number:

Current Driver’s Licence I.D.	Y N	Expires
Current WHMIS Certificate	Y N	Expires
Current First Aid Certificate	Y N	Expires
Current Dangerous Goods Certificate	Y N	Expires
Used PPE appropriately	Y N	Expires

If no, suggested improvements:

	Outcome :
Demonstrates lock-out and tag-out procedure	/8
Performs pre-operational inspection	/9
Communicates on the worksite	/10
Evaluates job conditions and determines method of approach	/5
Secures unattended equipment	/4

Demonstrated on-site (provide overview):