Title Page

  • Conducted on

  • Prepared by

  • Location

OSHA 1910 Subpart G

  • Has the facility been evaluated for occupational noise exposure? Date of last review

  • Has a program been established? Last review date:

  • Is required exposure monitoring, audiometric testing and medical monitoring conducted?

  • Has a recordkeeping program been established?

OSHA 1910 Subpart I

  • Has an assessment been completed and certified regarding the need for PPE (eye, face, head, hand, foot, and respirator protection)

  • Is PPE properly maintained in a sanitary and safe working condition?

  • Are there instances of necessary for fit testing to be conducted?

OSHA 1910 Subpart N

  • Are guards provided as needed to protect powered industrial trucks from undesirable contact?

  • Is fuel handling and storage compliant with NFPA 30 and 58?

  • Are operators trained, tested, licensed and observed in the use and handling of powered industrial trucks, by a properly authorized person?

  • Notes/observations:

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