Name:
Address:
Postal Code:
Tel. Number:

		Expires:
Current Driver’s Licence ID
Current WHMIS Certificate
Current First Aid Certificate
Current Dangerous Goods Certificate

	Yes	No
Used PPE appropriately: Comments:
Demonstrated lock-out and tag-out procedure
Performed pre-operational inspection
Communicates on the worksite
Demonstrated on Site: Provide overview
Evaluated job conditions and determine method of approach
Secures unattended equipment

Essential Skills/Employability

Assessor:
Print Name:
Signature

Applicant:
Print Name:
Signature

Location of Field Test:

Date: