## AWS D1.1 STRUCTURAL WELDER CERTIFICATION

**Welder’s Name**  
Welding Procedure Specification No.:

**Identification No.**  
Rev

| Variables                                             | Record Actual Values Used in Qualification | Qualification Range |     |     |
|------------------------------------------------------|-------------------------------------------|---------------------|-----|-----|
| Process/Type [Table 4.10, Item (2)]                |                                           |                     |     |     |
| Electrode (single or multiple) [Table 4.9, Item (9)]|                                           |                     |     |     |
| Current/Polarity                                     |                                           |                     |     |     |
|                                                      |                                           |                     |     |     |
| Position [Table 4.10, Item (5)]                     |                                           |                     |     |     |
| Weld Progression [Table 4.10, Item (7)]             |                                           |                     |     |     |
|                                                      |                                           |                     |     |     |
| Backing(YES or NO)[Table 4.10, Item(8)]            |                                           |                     |     |     |
| Material/Spec.[Table 4.10, Item(1)]                 | to                                        |                     |     |     |
| Base Metal                                          |                                           |                     |     |     |
| Thickness:(Plate)                                   |                                           |                     |     |     |
| Groove                                              |                                           |                     |     |     |
| Fillet                                              |                                           |                     |     |     |
| Thickness:(Pipe/tube)                               |                                           |                     |     |     |
| Groove                                              |                                           |                     |     |     |
| Fillet                                              |                                           |                     |     |     |
| Diameter:(Pipe)                                     |                                           |                     |     |     |
| Groove                                              |                                           |                     |     |     |
| Fillet                                              |                                           |                     |     |     |
| Filler Metal[Table 4.10, Item(3)]                   |                                           |                     |     |     |
| Spec.No.                                           |                                           |                     |     |     |
| Class                                               |                                           |                     |     |     |
| F-No.                                              |                                           |                     |     |     |
| Gas/Flux Type[Table 4.10, Item(4)]                 |                                           |                     |     |     |
| Other                                               |                                           |                     |     |     |

| VISUAL INSPECTION(4.8.1)Acceptable□YES or□NOGuided Bend Test Results(4.30.5) |     |     |     |
|-------------------------------------------------------------|-----|-----|-----|
| Type                        | Result | Type   | Result |
|-----------------------------|--------|--------|--------|
|                             |        |        |        |
| Fillet Test Results(4.30.2.3and4.30.4.1) |    |    |    |
| Appearance                     |        | Fillet Size  |        |
| Fracture Test Root Penetration |        | Macroetch    |        |
| (Describe the location,nature,and size of any crack or tearing of the specimen.) |        |  |     |
| Inspected by          |        | Test Number  |        |
| Organization          |        | Date        |        |

| RADIOGRAPHIC TEST RESULTS(4.30.3.1)                 |     |     |     |     |     |     |
|-----------------------------------------------------|-----|-----|-----|-----|-----|-----|
| Film Identification #  | Results | Remarks | Film Identification #  | Results | Remarks |
|------------------------|--------|---------|------------------------|--------|---------|
|                        |        |         |                        |        |         |
|                        |        |         |                        |        |         |
| Interpreted by  |     | Test Number |     |     |     |
| Organization      |     | Date        |     |     |     |

We, the undersigned, certify that the statements in this record are correct and that the test welds were prepared, welded, and tested in accordance with the requirements of section 4 of ANSI/AWS D1.1, () Structural Welding Code-Steel.  
(year)

Organization

**Date By**

DCR 10003

FN 5.005.6 (Rev. 1)