Technician Safety Competency Assessment Form
Use this form to evaluate a technician’s safety knowledge, PPE use, hazard awareness, safe work practices, and readiness to work safely.
Technician Information
Technician Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Department / Team
*
Work Location / Site
*
Supervisor / Assessor Name
*
First Name
Middle Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Number (Optional)
Safety Training and Qualification Status
Current Safety Training Status
*
Current
Expired
Pending
Not Applicable
Required Certifications Completed
*
Working at Heights
Lockout/Tagout
Electrical Safety
Confined Space
Forklift Operation
First Aid
Other
Last Refresher Training Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization to Perform Assigned Tasks
*
Authorized
Restricted
Pending Review
Not Applicable
PPE and Site Safety Compliance
Proper PPE Selection
*
1
2
3
4
5
Consistent PPE Use
*
1
2
3
4
5
Inspection of PPE Before Work
*
1
2
3
4
5
Adherence to Site Safety Rules
*
1
2
3
4
5
Housekeeping Standards
*
1
2
3
4
5
PPE Compliance by Item
*
Rows
Compliant
Not Compliant
Not Applicable
Hard Hat
1
2
3
Eye Protection
4
5
6
Gloves
7
8
9
Footwear
10
11
12
Hearing Protection
13
14
15
High-Visibility Wear
16
17
18
Hazard Recognition and Control
Which workplace hazards can you identify in a typical technician work area?
*
Electrical energy
Moving machinery
Stored pressure
Hot surfaces
Slips, trips, and falls
Chemical exposure
Confined spaces
Other
What is the best immediate control when a hazardous condition cannot be eliminated right away?
*
Stop the task and make the area safe
Continue with extra caution
Wait and report it later
Ask another technician to proceed
Rate the technician’s ability to apply hazard controls in the following situations.
*
Rows
Not Demonstrated
Partially Demonstrated
Competent
Identifies the hazard
19
20
21
Selects effective controls
22
23
24
Verifies isolation or lockout/tagout where required
25
26
27
Uses barriers, signs, or guarding appropriately
28
29
30
Reports unsafe conditions promptly
31
32
33
Which actions are required before starting work on equipment that may contain stored energy?
*
Notify affected personnel
Shut down the equipment
Isolate all energy sources
Apply lockout/tagout or equivalent isolation
Release or restrain stored energy
Verify zero-energy state
Bypass the procedure to save time
Other
How confident is the technician in identifying hazards and reporting unsafe conditions?
*
1
2
3
4
5
Equipment, Tools, and Work Practice Safety
Safe use of tools and equipment
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Pre-use inspection habits
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Correct setup and operation of equipment
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Examples of safe work practices or observed gaps
Emergency Response and Incident Reporting
First response action for a serious injury
*
Stop work and make area safe
Call emergency services and follow site procedure
Move the person immediately to another area
Leave and report later
Which incident reporting steps do you know and would follow?
*
Notify supervisor or site lead
Provide immediate first aid if trained
Record details in the incident report
Report near misses as well
Preserve the scene if safe to do so
Other
Primary evacuation or communication channel during an emergency
*
Two-way radio
Site alarm system
Muster point warden
Phone call to site contact
Other
Confidence in emergency response and incident reporting procedures
*
1
2
3
4
5
Assessor Evaluation and Outcome
Overall Competency Rating
*
1
2
3
4
5
Assessment Outcome
*
Competent
Not Yet Competent
Key Strengths
Improvement Areas
Required Retraining or Follow-up Actions
Final Comments
Submit Assessment
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