MMA PREVENT Forklift Evaluation Form

• Operator Name:

• Evaluator Name:

• Client:

• Conducted on

  Date

• Authorized Equipment:

Inspection

• Does the company perform inspections each shift the forklift is used? Does the operator know where the inspection form is located?

  Safe

  At Risk

  N/A

Mounting

• 3 points of control facing the forklift?

  Safe

  At Risk

  N/A

• Seat belt used?

  Safe

  At Risk

  N/A

• Disengage parking break?

  Safe

  At Risk

  N/A

Picking up & Placing Load

• Square up on center of the load:

  Safe

  At Risk

  N/A

• Make sure there is sufficient clearance for the load:

  Safe

  At Risk

  N/A

• Stop with the forks tips about 1 foot from the load:

  Safe

  At Risk

  N/A

• Clears personal from the area near the load:

  Safe

  At Risk

  N/A

• Levels the forks; then slowly approaches the load until the load contacts the carriage:

  Safe

  At Risk

  N/A

• Lifts the load carefully and smoothly until it is clear:

  Safe

  At Risk

  N/A

• Tilts the mast back slightly to stabilize the load:

  Safe

  At Risk

  N/A

• Looks over both shoulders before lowering the load:

  Safe

  At Risk

  N/A

• After out and stopped, lowers the load to traveling height:

  Safe

  At Risk

  N/A

• Raise the load to placement level:

  Safe

  At Risk

  N/A

• Lower forks to traveling position:

  Safe

  At Risk

  N/A

Traveling with load

• Does not raise or lower the forks while traveling, if needed stops before raising or lowering then continues traveling:

  Safe

  At Risk

  N/A

• Maintains safe speed:

  Safe

  At Risk

  N/A

• Observes all traffic rules, warning signs, floor load limits, and overhead clearances:

  Safe

  At Risk

  N/A

• Keeps arms, hands, legs, and feet inside the roll over cage at all times:

  Safe

  At Risk

  N/A

• Follows other vehicles at safe distance:

  Safe

  At Risk

  N/A

• Slows down when cornering:

  Safe

  At Risk

  N/A

• Uses horn to alert others:

  Safe

  At Risk

  N/A

• Travels with load facing uphill while on a ramp or incline:

  Safe

  At Risk

  N/A

• Stops smoothly:

  Safe

  At Risk

  N/A

Parking

• Fully lower forks:

  Safe

  At Risk

  N/A

• Neutralizes controls:

  Safe

  At Risk

  N/A

• Sets the brakes:

  Safe

  At Risk

  N/A

• Turn off power:

  Safe

  At Risk

  N/A

• If parked on incline, block the wheels:

  Safe

  At Risk

  N/A

• Park only in authorized areas:

  Safe

  At Risk

  N/A

Fueling And or Battery Recharging

• Engine off:

  Safe

  At Risk

  N/A

• Fire extinguisher nearby:

  Safe

  At Risk

  N/A

• Proper personal protective equipment, have them list what they would wear for refueling, adding water, recharging, etc :

  Safe

  At Risk

  N/A

• Spills cleaned up immediately: How would they clean up a spill?

  Safe

  At Risk

  N/A

• Ensure following safe fueling and recharging procedures:

  Safe

  At Risk

  N/A

Evaluation Assessment

• Based on my evaluation the operator has successfully completed the evaluation and is qualified to operate the equipment listed I. The authorized equipment section above.

  Yes

  No

  N/A

• Operators Signature

  Sign

• Evaluators Signature

  Sign