Sysco St. Louis Powered Industrial Equipment Certification

• Employee

• Certification Type

  Select initial 3 Year Recertification Retrain

  • initial
  • 3 Year Recertification
  • Retrain

• Equipment Type

  Select Crown Single Pallet Jack Crown Double Pallet Jack Crown Triple Pallet Jack Raymond Triple Pallet Jack Crown Forklift Raymond Forklift Hi Reach Scissor Lift

  • Crown Single Pallet Jack
  • Crown Double Pallet Jack
  • Crown Triple Pallet Jack
  • Raymond Triple Pallet Jack
  • Crown Forklift
  • Raymond Forklift
  • Hi Reach
  • Scissor Lift

• Conducted on

  Date

• Prepared by

Equipment

• Proper pre-trip inspection.

  Yes

  No

  N/A

• Read vehicle data plate.

  Yes

  No

  N/A

• Reviewed proper procedure for reporting damaged or defective equipment.

  Yes

  No

  N/A

Vehicle Operation

• Looks in the direction of travel before moving one inch.

  Yes

  No

  N/A

• Operated from the designated operating position. Four points of contact with the equipment and all body parts are inside the equipment.

  Yes

  No

  N/A

• Follows procedures at blind intersections/pedestrians. S.L.Y. - Slow down, Lay on horn and Yield at all intersections, doorways, curtains, blind spots and when approaching pedestrians.

  Yes

  No

  N/A

• Reasonable and safe speed.

  Yes

  No

  N/A

• Changes direction "plugging."

  Yes

  No

  N/A

• Looks before backing up.

  Yes

  No

  N/A

• Remove debris from travel path.

  Yes

  No

  N/A

• Uses required safety equipment (seatbelt/harness).

  Yes

  No

  N/A

• Emergency and normal braking.

  Yes

  No

  N/A

• Distance of forks from floor.

  Yes

  No

  N/A

• Safe distance from other lifts or objects.

  Yes

  No

  N/A

• Complete stop before dismount.

  Yes

  No

  N/A

• Keeps to the right.

  Yes

  No

  N/A

• Courtesy to other operators. No horseplay.

  Yes

  No

  N/A

• Does not was on empty fork or pallets.

  Yes

  No

  N/A

• Safe following distance.

  Yes

  No

  N/A

Pick/Deposit Load

• Good approach and placement of load.

  Yes

  No

  N/A

• Load distributed and stable.

  Yes

  No

  N/A

• Forks positioned and lift centered.

  Yes

  No

  N/A

• Lifting and lowering speed.

  Yes

  No

  N/A

• Forward movement into rack.

  Yes

  No

  N/A

• Alignment and penetration into pallet.

  Yes

  No

  N/A

• Proper use of tilt, lift and side shift.

  Yes

  No

  N/A

• Stopped forklift before load is raised or lowered.

  Yes

  No

  N/A

• Checks for overhead obstructions.

  Yes

  No

  N/A

• Looks in the direction of travel before backing.

  Yes

  No

  N/A

Battery

• Knows location of eyewash and shower station.

  Yes

  No

  N/A

• Employee confirmed training on BHS (Battery Handling System).

  Yes

  No

  N/A

• Proper connecting and disconnecting from charger.

  Yes

  No

  N/A

Scissor Lift/ Hi Reach

• Trained on the use of fall arrest equipment.

  Yes

  No

  N/A

• Proper inspection of full body harness and self retracting lanyard.

  Yes

  No

  N/A

• Tethered before moving equipment one inch.

  Yes

  No

  N/A

Media

• Picture of employee operating equipment.

  Media

• Employee Signature

  Sign

• I, the undersigned, certify that the above listed employee is proficient in the operation of Powered Industrial Equipment (PIE) as defined in 29 CFR 1910.178.

• Supervisor Signature

  Sign