Annual Program Review - Powered Industrial Vehicle (PIV)

• Audit Title

• Site Name

• Conducted on

  Date

• Auditor

• Location
  Address

• Site EHS Manager

Applicable Standards

• Select those standards that apply.

  Select 29CFR1910.178, "Powered Industrial Trucks" EHS&S Standard 22, Powered Industrial Vehicle

  • 29CFR1910.178, "Powered Industrial Trucks"
  • EHS&S Standard 22, Powered Industrial Vehicle

Documents Reviewed

• Written Program

• Powered Industrial Vehicle Surveillance Records

• Training Program

• Training Records

• List of PIV operators

• Accident or near miss investigations

• Site specific documents

Program Execution

• Is there an IOSS program leader on site?

  Yes

  No

  N/A

• How many people operate PIVs?

  0 to 5

  5 to 10

  10 to 50

  50+

• Are PIV operators removed from driving PIV's until retrained if they are involved in an accident or near miss?

  Yes

  No

  N/A

• Are the PIVs on a PM program?

  Yes

  No

  N/A

• Were there any accidents or near misses associated with PIVs? If yes, review and provide outcome of investigation to prevent re-occurance.

Training

• What is the frequency of training?

  Select Initial Annual Every 3 Years Initial Only

  • Initial
  • Annual
  • Every 3 Years
  • Initial Only

• Does the training program cover the required program elements?

  Yes

  No

  N/A

• Describe the training program.

• Who serves as the certified trainer?

  Company employee

  Vendor

• Are operators re-trained upon any of the following: Operator is observed operating in an unsafe manner; Operator is involved in an accident or near miss; Operator receives an evaluation that they are not operating the truck in a safe manner; Operator is assigned to a different type of PIV; or a condition in the workplace changes in a manner that could affect safe operation of the truck.

  Yes

  No

  N/A

Medical Evaluation

• Is the list of participants in the PIV medical surveillance program aligned with the list of employees who operate PIVs?

  Yes

  No

  N/A

• What is the system for notifying those who operate PIVs when they are due for medical surveillance?

Employee Discussions

• Discussions were held with the following groups or employees on site. List number of people when applicable.

Plant Tour

• Were operators observed wearing seat belts?

  Yes

  No

  N/A

• Are pre-use inspections conducted and documented on every shift? (review completed inspections)

  Yes

  No

  N/A

• What is the process to address repairs or unsatisfactory conditions identified on the pre-use inspection checklist?

• Is there a process to remove a PIV from service if a pre-use inspection identifies an unsafe condition or PIV in need of maintenance?

  Yes

  No

  N/A

• Describe process for removing PIV from service.

• Are dock locks and / or chocks engaged prior to PIV's entering trucks or trailers?

  Yes

  No

  N/A

• Are jack stands used with trailers that are not connected to trucks?

  Yes

  No

  N/A