DOA FORKLIFT OPERATOR EVALUATION

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date & time

  Date

• Evaluator

  Hill

  Gardner

  Giesler

  Elkins

  Habersack

• Operator

• Badge

• Section/shop

Pre-use inspection

• Forklift asset number

• Fuel/battery

  Safe

  At Risk

  N/A

• Photo

  Media

• Hydraulic fluid level

  Safe

  At Risk

  N/A

• Mast

  Safe

  At Risk

  N/A

• Carriage

  Safe

  At Risk

  N/A

• Forks

  Safe

  At Risk

  N/A

• Backrest

  Safe

  At Risk

  N/A

• Overhead guard

  Safe

  At Risk

  N/A

• Nuts & bolts

  Safe

  At Risk

  N/A

• Fluid leaks

  Safe

  At Risk

  N/A

• Wheels/tires

  Safe

  At Risk

  N/A

• Safety belt

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Backup alarm

  Safe

  At Risk

  N/A

• Gauges/warning lights

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Controls

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Hand brake

  Safe

  At Risk

  N/A

• Red tag - out of service?

Operating area

• Operating surface

  Safe

  At Risk

  N/A

• Overhead obstructions

  Safe

  At Risk

  N/A

• Housekeeping

  Safe

  At Risk

  N/A

• Traffic

  Safe

  At Risk

  N/A

• Pedestrians/bystanders

  Safe

  At Risk

  N/A

• PPE required

  yes

  no

• No smoking

  Safe

  At Risk

  N/A

• Load capacity

  Safe

  At Risk

  N/A

Operation

• Safety belt use

  Safe

  At Risk

  N/A

• Running lights used

  Safe

  At Risk

  N/A

• Horn use

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Controls

  Safe

  At Risk

  N/A

• Fork position

  Safe

  At Risk

  N/A

• Approach load

  Safe

  At Risk

  N/A

• Engage load

  Safe

  At Risk

  N/A

• Lift load

  Safe

  At Risk

  N/A

• Mast tilt

  Safe

  At Risk

  N/A

• Travel posture

  Safe

  At Risk

  N/A

• Speed

  Safe

  At Risk

  N/A

• Cornering

  Safe

  At Risk

  N/A

• Deposit load

  Safe

  At Risk

  N/A

• Lowering forks

  Safe

  At Risk

  N/A

• Photo

  Media

Shut down

• Select location

  Safe

  At Risk

  N/A

• Set down forks

  Safe

  At Risk

  N/A

• Forks flat

  Safe

  At Risk

  N/A

• Controls neutral

  Safe

  At Risk

  N/A

• Engine off

  Safe

  At Risk

  N/A

• Key removed

  Safe

  At Risk

  N/A

• Set brake

  Safe

  At Risk

  N/A

• Chock wheels

  Safe

  At Risk

  N/A

• Photo

  Media

Evaluator comments

• Pass?

  Yes

  No

  N/A

• Comments

• Evaluator

  Sign

• Operator

  Sign