Aerial Lift Safety Assessment
Complete this form to document the safety inspection and condition of an aerial lift prior to use.
Inspector Name
*
First Name
Last Name
Inspection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Aerial Lift Identification (Model/Serial Number)
*
Pre-Operation Safety Checklist
*
Rows
Pass
Fail
N/A
Controls operational
1
2
3
Safety devices in place
4
5
6
Hydraulic system checked
7
8
9
Guardrails secure
10
11
12
Wheels/tires inspected
13
14
15
Any hazards or defects identified?
*
No hazards or defects found
Hazards or defects identified (describe below)
If hazards or defects were identified, describe them:
Corrective actions taken (if any)
Supervisor/Responsible Person Name
*
First Name
Last Name
Submit Assessment
Should be Empty: