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1.0 General
Date of lift
Description of the object to be raised:
Lift description:
Diagram of Crane Lift and Load Placement Attached? ____ Yes ____No
Diagram of Rigging and Load Attached? ____ Yes ____No
Does this lift Involve Lifting Personnel? ____ Yes ____No
2.0 How weight of the object was obtained

3.0 Stability of Ground Area

Certified scale weight (lbs)

Soil or pavement bearing capacity:

Scale weight ticket number:

Source of soil or pavement information:

Calculated independently by more than one source:

Size of mats:

Source 1:

Number of mats:

Weight (lbs):

Any underground installations? ____ Yes ____No

Source 2:

Ratio of soil bearing capacity to actual

Weight (lbs):
3.0 Load Calculations

4.0 Crane Information

Load condition ____ New ____Used

Type of crane _____________________

Crane capacity (tons)

Weight empty ( Load or Basket) (lbs)

Max. dist. center of load to center pin (ft)

Weight of contents (lbs)

Rated capacity in tons of crane

Weight of aux. block or headache ball (lbs)

Over Rear (tons)

Weight of main block (lbs)

Over Front (tons)

Weight of lifting beam/bar (lbs)

Over Side (tons)

Weight of slings and shackles (lbs)

Length of Boom (ft)

Weight of jib (erected or stowed) (lbs)

Weight of hoist rope (extra) (lbs)

5.0 Jib Use

Weight of excess load material (lbs)

Erected_____ Stored ____

Allowance for Unaccounted Material (lbs)

Is Jib to be used ? ____ Yes ____No

Others (lbs)

Length of Jib (ft):

Total Weight (lbs)

Total Weight (tons)

Angle of Jib (deg):

Rated Capacity of Jib (from chart) (tons):

Source of Load Weight Information

Weights Verified By:
5.0 Lifting Arrangement
Radius at pick up (ft)

Maximum Rated Capacity of crane at this

Radius at set down (ft)

Radius and Boom Angle for this lift (tons):

Crane capacity at radius (tons):

Maximum Load (tons) on Crane is:

Crane capacity over side (tons):

Percent of lift to cranes rated capacity

Crane capacity over rear (tons):

Clearance between boom and lift (ft):

Crane capacity over front (tons):

Clearance to surrounding facilities (ft):

Boom angle at pick up (deg):

Clear path for load movement ____ Yes ____No

Boom angle at set down (deg):


7.0 Cable- Hoist Rope

8.0 Rigging

Size of Cable (diameter in inches)

Type Sling Arrangement or Hitch arrangement _________________

Number of Parts of Cable

Number of Slings in hook-up

Lift capacity based on parts/load (tons):

Sling Length (ft):

Rated capacity of slings (lbs):
Shackle size
Shackle capacity (tons)
Number of shackles
Shackle attached to load by

9. 0 Crane Placement

10.0 Pre-Lift Checklist

Any deviation from smooth solid foundation in the area?

Crane inspected


Crane set up


Matting acceptable


Outriggers fully extended

Electrical Hazards in the Area ?

Load chart in crane


Rigging inspected


Swing room checked


Hoist height checked

Obstacles or Obstructions to Lift or Swing ?

Head room checked


Crane counterweight used


Load test performed


Operator qualified

Obstacles in travel?

Signal system established


Flagman (Safety Spotter) qualified


Rigger qualified


Tag lines ready and used

Swing Direction and Degree ( Boom Swing )

Wind and climate acceptable


Traffic controlled




Site controlled

Special Instructions or Restrictions for Crane, Rigging or lift, Etc:


11.0 Critical Lift Approvals

Crane inspectors signature and date
Rigging inspectors signature and date
Lift supervisors signature and date
Project engineer signature and date
Project managers signature and date
Signal men names
Crane operator name