Appendix C-QCC LE01 (Template)

Certificate of Thorough Examination-Lifting Gears Safe

C-1 Certificate of Thorough Examination –(Lifting Gears Safe)
Date of Through Examination: Date Of Report: Report number:

Refrences(s) Color Code

Name and Address of employer for whom the thorough Address of premises at which the examination was
made:
examination was made:

Description and identification of the equipment: Safe Date of Date of last

working manufacture if thorough
load(s): known: examination:

Date of Last Proof Load Test: Date of Next Proof Load Test:

Was the examination carried out:

Is this this the first examination after installation or Within an interval of 6 Yes No
months?
assembly at a new site or location? Yes No
Yes No
Within an interval of 12
months?
If the answer to the above question is YES
Yes No In accordance with an Yes No
Has the equipment been installed
examination scheme?
correctly?
After the occurrence of Yes No
exceptional circumstances?

Identification of any part found to have a defect which is or could become a danger to persons and a
description of the defect: (If none state NONE)

Is the above a defect which is of immediate danger to persons Yes No

Is the above a defect which is not yet but could become a danger to Yes by:
persons: (If yes state the date by when)
Particular of any repair, renewal or alteration required to remedy the defect identified above:

Particular of any tests carried out as part of the examination: (if none state NONE)

IS THEIS EQUIPMENT FIR FOR PURPOSE? Yes No

Name & Qualification of person Name of person Latest date by which next thorough
authenticating this report: examination must be carries out:
making this report:
Name and address of employer of persons making and authenticating this report:

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