Periodic Examination Checklist

Model Number:		Serial Number:
Date:		Inspector (Name / Signature):
Date of Manufacture:		Date of Purchase:
Date of First Use:		Date Due for Next Periodic Inspection:

 

#	Description	Good—Safe for Use	Good—Safe for Use	Good—Safe for Use	Good—Safe for Use	Good—Safe for Use	Good—Safe for Use	Damaged, Worn, Altered, Missing—Remove from Service	Comments
Connectors
1	Aluminum swivel carabiner
12	Aluminum carabiner
Energy Absorber & Lifeline Components
2	Energy absorber
3	Lifeline
5	Cable end stop + cable wrap
Hardware Components
4	Bypass shuttle
6	Cable clamp
8	Cable lock
9	Tension lock nut
10	Turnbuckle
11	Tension indicator
Labels
7	Manufacture date, serial number, part number, warning
	Steel anchorage sling (2), optional