Title Page
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Name of Person Undergoing Evaluation
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Conducted on
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Location/Task
MHE Operation
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MHE type/Fleet number
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Pre Use Check Complete (Attach Photo)
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Is the MHE being operated safely accordingly to training, observing hazards and work areas?
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Is the operator wearing their seatbelt?
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Is the operator maintaining a safe distance from other MHEs and pedestrians?
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Is the operator free of any correctional measures required? (If so, add details in comments)
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If a toolbox talk is required, enter the words of advice given: (if N/A write N/A in notes)
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Name & Signature of Operator (by signing this you agree to the evaluation and any words of advice/ toolbox talk given)
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Name & Signature of Evaluator
