Powered Industrial Truck Authorisation Form

• Conducted on

  Date

• Prepared by

• Location Of Assessment/ Review
  Address

• Name of Operator Authorised

  Tony Robertson

  Mike Watson

  Dillion Wylam

  Cohen Loud

  other

• Name of Operator

• Employer if not JFL

• Type of Powered Industrial Truck Operator Authorised to Operate

  Select Reach Truck Counter Balanced Truck Pallet Pump Truck Other

  • Reach Truck
  • Counter Balanced Truck
  • Pallet Pump Truck
  • Other

• Details of type of Powered Industrial Lifting Truck

• Locations Operators is Authorised to Operate

  Select Ottery Moor Lane, Honiton Warehouse Park Court, Honiton Warehouse Other

  • Ottery Moor Lane, Honiton Warehouse
  • Park Court, Honiton Warehouse
  • Other

• Details of other locations

Training

• Training details

• Expiry Date of Training

  Date

• Provide photo of training certificate(s)

  Media

Location Awareness and Rule

• The Authorised Operator has been trained in all the Site rules

  Yes

  No

  N/A

• The Authorised Operator has read and signed all relevant Safe systems of Work.

  Yes

  No

  N/A

Competency Assessment - Using Powered Industrial Truck Operators Performance Evaluation

• Competency assessment completed and Operator has achieved an adequate score to demonstrate suitable competency

  Yes

  No

  N/A

• A suitable frequency of Operator performance evaluation has been set

Fitness to Operate Powered Industrial Trucks

• Operator has passed a Drugs and Alcohol test

  Yes

  No

  N/A

• Are there any health issues which may affect the Operators cabilty to safely Operate

  Select No Yes but suitable adjustments made Yes

  • No
  • Yes but suitable adjustments made
  • Yes

• Provide details of Suitable adjustments - indicate if permanent or temporary.

Sign Off Section

• Operator sign to demonstrate they understand the rules and safety measures required for operating a Powered Industrial Truck for Jurassic Fibre. They undertake to operate these safely and inform manager if they have any health conditions requiring prescription medication or if they know of any other concern that could affect ability to operate these safely.

  Sign

• Manager sign to demonstrate that the assessment has been fair and robust and they feel the Operator is competent to operate the Powered Industrial Trucks indicated and that he will undertake to ensure suitable competency assessments are undertaken to monitor compliance with rules and expectations.

  Sign