Title Page
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Conducted on
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Prepared by
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Location
OSHA 1910 Subpart G
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Has the facility been evaluated for occupational noise exposure? Date of last review
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Has a program been established? Last review date:
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Is required exposure monitoring, audiometric testing and medical monitoring conducted?
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Has a recordkeeping program been established?
OSHA 1910 Subpart I
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Has an assessment been completed and certified regarding the need for PPE (eye, face, head, hand, foot, and respirator protection)
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Is PPE properly maintained in a sanitary and safe working condition?
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Are there instances of necessary for fit testing to be conducted?
OSHA 1910 Subpart N
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Are guards provided as needed to protect powered industrial trucks from undesirable contact?
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Is fuel handling and storage compliant with NFPA 30 and 58?
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Are operators trained, tested, licensed and observed in the use and handling of powered industrial trucks, by a properly authorized person?
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Notes/observations: