Aerial Lift Operator Safety Questionnaire Form
Complete this form to assess your readiness and work conditions for aerial lift operation.
Operator Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Certification/Training Status
*
Currently certified and up-to-date
Certification expired
Not certified
Type of Aerial Lift/Equipment Used
*
Please Select
Scissor Lift
Boom Lift
Personnel Lift
Trailer-Mounted Lift
Other
Job Site or Work Environment
*
Please Select
Warehouse/Indoor Facility
Construction Site (Outdoor)
Industrial Plant
Maintenance Area
Other
Has a pre-use inspection been completed today?
*
Yes, no issues found
Yes, issues found (see below)
No
If equipment issues were found, please describe them.
Have there been any recent incidents or near-misses involving aerial lift operation?
*
No incidents or near-misses
Yes, incident reported
Yes, near-miss reported
List any current safety concerns related to aerial lift operation.
I confirm that the information provided in this safety questionnaire is accurate to the best of my knowledge.
*
I confirm the above statement
Submit
Should be Empty: