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	Damaged, Worn, Altered, Missing—Remove from Service	Comments
Connectors
1	Steel swivel carabiner
8	Steel carabiner
Energy Absorber & Lifeline Components
2	Energy absorber
3	Sewn Termination
4	Lifeline
6	End Stop
Hardware Components
5	Bypass shuttle
7	Tensioner
9	Folding tension handle
10	Release handle
	Steel anchorage sling (2), optional
Labels
11	Manufacture date, serial number, part number
12	Product and warning labels