Employee Observation Report

• Heavy Equipment Operator Observation Report Employee Name

• Unit number

• Document No.

• Location

  Landfill

  Jackson Pike

  Morse rd

  Fleet

  Operations

• Conducted on

  Date

• Prepared by

• DVIR completed prior to operating

  Yes

  No

  N/A

Equipment Condition

• Backing Alarm

  Yes

  No

  N/A

• Lights

  Yes

  No

  N/A

• Gauges/Controls

  Yes

  No

  N/A

• Parking Brake

  Yes

  No

  N/A

• Horn

  Yes

  No

  N/A

• Overhead Unobstructed

  Yes

  No

  N/A

Training

• Operator Qualification Training ( Ask employee when the last time was they put through recertification )

  Ok

  Needs Attention

  N/A

• Training Properly Documented (Contact Bernie Janitia if unsure)

  Ok

  Needs Attention

  N/A

• Knows Load Capacity

  Ok

  Needs Attention

  N/A

• Knows Maximum Overhead Reach

  Ok

  Needs Attention

  N/A

Operating Skills

• Travel Speed-Forward

  Yes

  No

  N/A

• Travel Speed-Reverse

  Yes

  No

  N/A

• Use of Controls

  Yes

  No

  N/A

• Stopping/Use of Brakes

  Yes

  No

  N/A

• Load Carry Position

  Yes

  No

  N/A

• Use of Parking Brakes

  Yes

  No

  N/A

• Leaves Mast Vertical and Forks Down

  Yes

  No

  N/A

Personal Safety

• Hard Hat as Required

  Yes

  No

  N/A

• 6" High Work Boots

  Yes

  No

  N/A

• ANSI Class 2 Vest and Clothing

  Yes

  No

  N/A

• Safety Glasses

  Yes

  No

  N/A

• Mount/Dismount (3 pt contact)

  Yes

  No

  N/A

• Uses Seat Belts

  Yes

  No

  N/A

• Any Other Unsafe Acts?

  Yes

  No

  N/A

Lock-out/Tag-out

• Was Equip LO/TO with Pad Lock & Tags ( if not in use ask employee where they are located)

  Yes

  No

  N/A

• Was all Keys Removed ( If LO/TO is not in use at time of observation explain to employee why keys should be removed)

  Yes

  No

  N/A

• Employee understand LO/TO Principles

  Yes

  No

  N/A

• Employee know where to find LO/TO program for Reference

  Yes

  No

  N/A

• Employee Blocks or Chalks Wheels ( Explain to employee that they should be available in case of break down or for emergency use )

  Yes

  No

  N/A

• Operator Comments

• Operator Signature

  Sign

• Observer Comments

• Observer Signature

  Sign

• Add any Pictures Relevant to Observation

  Media

• Yes

  No

  N/A