Hayes Modular Group Inc.

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Assessor Competancy

• The assessor must be trained as per PUWER Regulation 9 Section 2.2 and have a full understanding of all plant vehicle operation that they are to assess. If you require further information, contact Ian Lumsden Tech IOSH, MIIRSM (ITSSAR Registered Instructor /Examiner ) by Email: Ian.lumsden2@gmail.com

Type and Model of reach fork

• Make

• Model

• SN#

Operator Details

• Has the operator a valid certificate of training that has been passed or refreshed within the last three years?

  Yes

  No

  N/A

• Date of test or refresher course?

  Date

• Has the operator an up to date authorisation to operate, signed and renewable annually?

  Yes

  No

  N/A

• Date of signed authorisation operate the plant vehicle?

  Date

Daily Safety Inspection

• The operator completes the safety Pre-shift safety inspection correctly

  Yes

  No

  N/A

• The operator fully understands the capacity information plate?

  Yes

  No

  N/A

• The operator understands the correct fault reporting procedures?

  Yes

  No

  N/A

• If a fault has been found, the lift truck must be parked up in a safe place and the key removed. The fault must be made to a member of the management team.

Operator Safety & Observation

• The operator mounts / dismounts correctly?

  Yes

  No

  N/A

• Uses the seatbelt correctly?

  Yes

  No

  N/A

• Keeps body parts within the confines of the vehicle?

  Yes

  No

  N/A

• Operator looks in the direction of travel?

  Yes

  No

  N/A

• Correct use of the horn when appropriate?

  Safe

  At Risk

  N/A

• Follows the correct procedures for an "unattended" vehicle?

  Yes

  No

  N/A

• Operator had good all round safety observation?

  Yes

  No

  N/A

Steering & Operating Controls

• Starts and stops smoothly?

  Yes

  No

  N/A

• Correct use of the steering assistor?

  Yes

  No

  N/A

• Travels unintentionally in the wrong direction?

  Safe

  At Risk

  N/A

• Brakes harshly / erratically?

  Safe

  At Risk

  N/A

• Releases the parking brake prior to moving off?

  Yes

  No

  N/A

• Operator rides the foot brake?

  Safe

  At Risk

  N/A

• Operates the hydraulic controls when the lift truck is in motion?

  Safe

  At Risk

  N/A

• Rough use of hydraulic controls?

  Safe

  At Risk

  N/A

• Operates and understands the controls?

  Safe

  At Risk

  N/A

Competency In Load Capacity

• Operator matches load with the trucks capacity?

  Yes

  No

  N/A

• Operator checks the load for stability?

  Yes

  No

  N/A

Manoeuvring & Transportation

• Forks to high when traveling?

  Yes

  No

  N/A

• Forks to low when traveling?

  Yes

  No

  N/A

• Operating in reverse, looking in the direction of travel to the correct ratio?

  Safe

  At Risk

  N/A

• Operates at a speed consistent with the type of load and working conditions?

  Safe

  At Risk

  N/A

• Operator performs safe manoeuvring with the lift truck and load!

  Yes

  No

  N/A

Stacking & de-stacking

• Incorrect set down at a vertical face?

  Safe

  At Risk

  N/A

• Operator applies the park brake when operating the hydraulics?

  Safe

  At Risk

  N/A

• Operator applies neutral when operating the hydraulics?

  Safe

  At Risk

  N/A

• Fork arms central under the load?

  Safe

  At Risk

  N/A

• Fork arms not rubbing (entry / withdrawal)?

  Safe

  At Risk

  N/A

• Fork tips touch the stack / load?

  Safe

  At Risk

  N/A

• Forks / load not level?

  Safe

  At Risk

  N/A

• Load correctly stacked?

  Safe

  At Risk

  N/A

• Fork arms not fully inserted (undercut) ?

  Safe

  At Risk

  N/A

• It is some times necessary to undercut a load due to the nature of where it is to be located. It must remain within the limits of the capacity plate.

Parking

• The operator correctly applies the park brake?

  Safe

  At Risk

  N/A

• The operator sets the direction lever to the neutral position?

  Safe

  At Risk

  N/A

• The operator correctly apples forward tilt?

  Safe

  At Risk

  N/A

• The operator correctly lowers the fork arms?

  Safe

  At Risk

  N/A

• The manoeuvring wheels are in the straight position?

  Safe

  At Risk

  N/A

• The operator switches off and removes the key?

  Safe

  At Risk

  N/A

Assessment Recommendations & Evaluations

• Assessors evaluation of operator safety?

  Excellent

  Good

  Satisfactory

  Re-training is advised

• Comments

Signatures

• Date and time of assessment

  Date

• Operator signature

  Sign

• Assessor signature

  Sign