Scissor Lift Operator

• Conducted on

  Date

• Prepared by

• Location
  Address

• Operators Name

Equipment Information

• Did the equipment undergo a quarterly preventive maintenance inspection? (Please upload a picture as evidence)

  Yes

  No

  N/A

Operator Documentation

• Does the Operator Hold a valid TSS issued PIT License? (Please upload a picture as evidence)

  Yes

  No

  N/A

• Does the operator have a PIT certified name badge in his vest? (Please upload a picture as evidence)

  Yes

  No

  N/A

• Operator certification documents uploaded into the safety share point? (Training Attendance + Assessment Evaluation + Copy of the PIT license + Retraining Attendance)

  Yes

  No

  N/A

• Did the Operator complete a pre-use inspections on forklift prior to operating?

  Yes

  No

  N/A

Forklift Safety Item Observed

• Please take pictures and add them to the questions as media as you complete this perfect practice observation. For any item not marked "NO" please provide appropriate follow up plans on the question.

• Operator fastens the safety chain?

  Yes

  No

  N/A

• Operator does not move the harness is fastened?

  Yes

  No

  N/A

• Operator drives at no more than 5 mph.

  Yes

  No

  N/A

• Scissor lift operator comes to a complete stop at intersections?

  Yes

  No

  N/A

• Scissor lift operator is "intentional" in their awareness at an intersection? Meaning- You see their head look left, right, and up to the mirror prior to proceeding.

  Yes

  No

  N/A

• Did you observe at least 2 instances where the scissor lift operator navigated an intersection?

  Yes

  No

  N/A

• Scissor lift operator visually checks to left and right side of lift to ensure clearance before traveling in reverse?

  Yes

  No

  N/A

• When descending, the operator ensures clearance and proceeds down slowly?

  Yes

  No

  N/A

• Scissor lift operator does not start to elevate until wheels are stopped?

  Yes

  No

  N/A

• Operator uses 3 points of contact getting on and off the scissor lift?

  Yes

  No

  N/A

• Operator wears proper PPE in the correct fashion? ie. Safety Vest Zipped Up

  Yes

  No

  N/A

• Operator Signature

  Sign

• Observer Signature

  Sign