Injury Illness Prevention Plan - Flipbook - Page 169
Health and Safety Program Manual
Teamwrkx
Construction, Inc.
Issue Date: 10/16/23
Revision Date: 10/16/23
Heavy Mobile Equipment Operation
Reference: A-11
APPENDIX C
HEAVY/MOBILE EQUIPMENT OPERATOREVALUATION/EMPLOYER CERTIFICATION FORM
Name of Operator:_____________________________________________________________
Equipment: __________________________________________________________________
Department:__________________________________________________________________
Date:________________________________________________________________________
Person Performing Evaluation:___________________________________________________
Department Head:_____________________________________________________________
This evaluation is to be completed upon completion of initial or refresher training of the heavy equipment
operator, and at a minimum frequency of every three years thereafter.
EMPLOYER CERTIFICATION
I certify that the individual identified above has been instructed and evaluated in the safe operation of the
equipment identified at the top of this form. Training and evaluation were conducted in accordance with The
Company’s Heavy Equipment Policy. The operator has been evaluated and been deemed competent in his
performance of the following:
x
x
x
x
x
Safely operates and does not abuse the equipment.
Completion of daily equipment inspections
Keeping equipment clean and serviceable
Practices good driving habits
Identifying and reporting equipment wear, malfunctions and damage
Evaluator________________________________________________________Date:________
Department Head _________________________________________________Date:________
16