Trainee Name____________________________

Trainee Social Security Number: ____________

Trainee Status:  _______

Course Name: ___________________

Course Code: ___________________                                 

National Center Course Number: ___________

Date Course Completed: ____________________

Performance Criteria Completed:  _____________

Performance Objectives:

                                                                                                                    Pass     Fail      

Topic 1: Ladders

1.1  Accurately identify various types of ladders and explain
how ladders are rated.

1.2  Demonstrate or describe how to select the proper type of
ladder for a job and then use the ladder safely.

Topic 2: Fixed Scaffolds

2.1 Accurately identify general safety precautions associated with
      stationary, or fixed, scaffolds.

2.2 Demonstrate or describe how to assemble, use, and disassemble
      a systems scaffold.

2.3 Demonstrate or describe how to assemble, use, and disassemble
      a tubular welded frame scaffold.

Topic 3: Powered Scaffolds

3.1 Accurately identify the basic components of a pneumatic
      scaffold and explain how the scaffold operates.

3.2 Accurately identify the basic components of a hydraulic
      scaffold and explain how the scaffold operates.

Performance Evaluator’s Signature _______________________________

Performance Evaluator’s Name (Print) ____________________________

Date Completed: _____________________________________________