MMA - Powered Pallet Jack Evaluation Form

• Operator Name:

• Client:

• Evaluator Name:

  Select Alanna Soukkala, CSP, OHST David Rumsey, CSP, CRM John Bestman, CSP, ASP Mike Music, CSP, ASP Scott Rief Shane Collins, MEHS, GSP, OHST Lindsey Hanson, CSP, CHST, CET

  • Alanna Soukkala, CSP, OHST
  • David Rumsey, CSP, CRM
  • John Bestman, CSP, ASP
  • Mike Music, CSP, ASP
  • Scott Rief
  • Shane Collins, MEHS, GSP, OHST
  • Lindsey Hanson, CSP, CHST, CET

• Conducted on

  Date

• Authorized Equipment:

Preuse Inspection

• Follow the Operator's Daily Checklist?

  Safe

  At Risk

  N/A

• Operator Looks for damage?

  Safe

  At Risk

  N/A

• Documents all findings on the checklist?

  Safe

  At Risk

  N/A

Picking up a Load

• Square up on center of the load:

  Safe

  At Risk

  N/A

• Moves under the load as far as possible:

  Safe

  At Risk

  N/A

• Raises the load until it is high enough for good floor clearance but low enough for stability:

  Safe

  At Risk

  N/A

Traveling with load

• Position for the best visibility both backward and forward:

  Safe

  At Risk

  N/A

• On a walkie-rider, keeps hands, feet and head clear of areas where they could be injured:

  Safe

  At Risk

  N/A

• Face the direction of travel:

  Safe

  At Risk

  N/A

• Maintains an appropriate, safe speed:

  Safe

  At Risk

  N/A

• Allows for wide swings around corners:

  Safe

  At Risk

  N/A

• Uses horn to alert others:

  Safe

  At Risk

  N/A

• Stops smoothly:

  Safe

  At Risk

  N/A

• Stops before raising or lowering the load:

  Safe

  At Risk

  N/A

• Come to a complete stop before stepping off a walkie-rider:

  Safe

  At Risk

  N/A

Putting Down a Load

• Steer the load into place with both hands on the controls:

  Safe

  At Risk

  N/A

• After the load is in place, glance behind to make sure it is clear:

  Safe

  At Risk

  N/A

• Watch for clearance:

  Safe

  At Risk

  N/A

• Carefully reverse direction:

  Safe

  At Risk

  N/A

Operators Behaviors

• 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