Competent Person Designation _____ Forklift _____ Front End Loader _____ Backhoe _____ Skip Loader _____ Excavation _____ Fall Protection _____ Scaffolding _____ Ladder Inspection _______ Fire Extinguisher Inspection _____ Other _______________________ ____ Other______________________ Description of Scope Description of Scope

__________________ ________________________________________________ Date of Training Provided By

__________________ ________________________________________________ Date of Training Provided By

__________________ ________________________________________________ Date of Training Provided By

__________________ ________________________________________________ Date of Training Provided By

____________________________________ has the knowledge, skills, training

and experience to recognize the hazards identified in the above scope of work

and has the authority to direct and take prompt corrective actions to address any

hazards. An evaluation was conducted on ______________. The evaluation

was based on typical activities that occur within the work environment.

I have explained the safety procedures and the inspection criteria. This

designation can and will be revoked upon demonstration of activities that are

deemed as unsafe.

______________________ ____________________________ _____________ Evaluated by Printed Name Evaluated by Signature Date

______________________ ____________________________ _____________ Competent Person Printed Name Competent Person Signature Date