IAEC - OSHA REQUIRED EVALUATION OF FORKLIFT OPERATION (Version 5)

• REC NAME

• OPERATOR NAME

• Conducted on

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• Prepared by

• Location
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SAFETY INFORMATION

• Has the operator been evaluated within the last three years?

  Yes

  No

• Did the operator attend classroom refresher training?

  Yes

  No

• Did the operator adequately perform a pre trip inspection?

  Yes

  No

• Checked that the forklift is in good operating condition - Wheels, foot brake, parking brake, hydraulics, forks etc.
  Checked that all safety features are operating - Strobe, flashers, horn, back up alarm, seatbelt etc.

• Is there a fire extinguisher on this forklift with a recent inspection date?

  Yes

  No

• Most recent inspection date

  Date

• Were any deficiencies identified during pre trip inspection?

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• Is the operator wearing the required PPE to operate the equipment at this location?

  Yes

  No

Fork Truck Information

• Type of equipment? (Standard forklift, skidsteer, other?)

• Select Standard forklift Skidsteer Tractor Other

  • Standard forklift
  • Skidsteer
  • Tractor
  • Other

• Make?

• Model?

• Serial Number?

• Capacity?

• Does this forklift have LP as a fuel source?

  Yes

  No

• Has there been any modifications made (not by the MFG) to the forklift?

  Safe

  At Risk

COURSE NAVIGATION

• Did the operator successfully complete the obstacle course?

  Yes

  No

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• Picture of the course Layout used for this training

  Media

• Did the operator safely park the forklift upon completion of the course? (including turning off the LP if applicable?)

  Yes

  No

Signatures

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• Safety Trainer's name

  John Dvorak

  Matt Pociask

  Jim Wolfe

  Scott Meinecke

• Safety trainer signature.

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• Operators Signature

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• Operators Signature

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• Additional Comments