CRANE OPERATOR RECORD

( To be submitted to Aneka Jaringan Sdn. Bhd. Safety Department before Crane comments work at site )

PROJECT :
CONTRACTOR :
OPERATOR NAME : NRIC No. : AGE :
1. QUALIFICATION
Driving License …………… Class 5 …………… Class 4 ……………. Class 3
Certificate of competency :
Date of Obtained : Valitity of License :
Safety / Other Certificates :
2. EXPERIENCE
Total number of years as crane operator :
Type of crane experience :
3. HEALTH CONDITION
Eyes are normal and no aliments Yes No
Eyes sight is 6/6 without glasses Yes No
No colour blindness Yes No
No loss of hearing Yes No
Upper and Lower limbs are not deformed / handicapped Yes No
If marked "NO" please provide details :
Have you ever had epilepsy (Fits)? Yes No
Have you ever been treated for any mental illness? Yes No
Do you have high blood pressure? Yes No
Are you presently under any medical treatment? Yes No
If marked "YES" please provide details :
The above mentioned in ormation provided by me is accurate to the best of my knowledge

Signature of crane operator : Date :

SAFETY DEPARTMENT
We confirmed the above named crane operator is medically fit, qualified and experienced for the job. We have instructed
him of the safety requirements on crane operation and authorised him to operate.

TYPE OF CRANE PMA NUMBER YEARS OF EXPERIENCE

Name : Signature :

Designation : Date :