Form No.

: IMS-QK-HSE-3-0057-34
Rev.00

Monthly Jack Hammer Inspection Checklist

PROJECT:

Contract No.:

Company:

Job No.:

For the Month of

Date of Inspection:

Inspected By:

Additional Comments:

Name and Signature:

Note: This checklist is referenced in procedure number: IMS-QK-HSE-3-0057

Tool Bit ( Sharp, Cracks, Length )

Tool Bit Receptacles ( with Lock )

Location

Air Hoses ( Leaks, Air Filters, Right

Fittings, Anti-Whiplash )

Serial No. /
Identification
No.

Hose Connections ( Right Fitting

with locks Anti-Whiplash )

Operator's Name

Handles ( Cracks, Sharp Edges )

Item
No.

Body ( Damage, Rust )

Inspection item

Remarks