Chapter 25
Machine Safeguarding—Shop and Lab Machine Safety

Appendix A
Example of an Application to Use Shop Equipment

Application to Use Shop Equipment

Name: _______________________________	Employee No.: __________________________

Shop Location: ________________________	Shop Manager: __________________________

Equipment Type: _______________________	Work Scope: ____________________________
	________________________________________
	________________________________________
Work Supervisor: _______________________	________________________________________

This individual has demonstrated safe operation of the type of shop equipment indicated and is qualified to use it for the scope of work listed above. General skills demonstrated:

____	Inspection of equipment prior to use (housekeeping, use of necessary
	guards, choice of appropriate tool, equipment in satisfactory condition)
____	Use of necessary guards
____	Use of necessary PPE (eyewear, face protection, footwear, skin protection,
	hearing protection, etc.)
____	Tool change (if applicable)
____	Power up
____	Safe use within work scope
____	Power down
____	Clean up

Equipment-specific skills demonstrated (list):

__________________________________________________________________________________________

Shop Manager Signature Date

Authorization to perform work on the above listed shop equipment to be provided by applicant’s line management.

_____________________

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Chapter 25 Machine Safeguarding—Shop and Lab Machine Safety

Appendix A Example of an Application to Use Shop Equipment

Chapter 25
Machine Safeguarding—Shop and Lab Machine Safety

Appendix A
Example of an Application to Use Shop Equipment