Title Page

  • Operators name

  • Prepared by

  • Date

  • Location

Untitled page

  • Performs pre-shift inspection?

  • Demonstrates knowledge of equipment

  • Correctly completes required inspection report?

  • Reports deficiencies to supervisor?

  • Wearing proper (PPE)?

  • Ensures all safety devices function properly - E-stop, warning lights, horn, etc.

  • Ensures all dashboard components function properly

  • Ensures parking brake works properly

  • Checks all moving parts for proper travel ( lift, lower, side movements, steering and drive operations)

  • Test all foot pedals

  • 3 points of contact entering and exiting cab

  • Slows down for pedestrians and sounds horn

  • Establishes eye contact with pedestrians

  • Does not allow pedestrians to come near equipment while operating

  • Aware of equipment overhang when moving and turning equipment

  • Never allows pedestrians to cross under load

  • Implements the use of a spotter to ensure all clear around equipment before and during movement

  • Performs all functions smoothly and consistently

  • Implements the use of hands free tools while placing dunnage under module and while holding lift chains in position when lifting in commenced.

  • Both operator and spotters are aware and avoid the pinch point between Combi-Lift and module.

  • Never leaves a load unattended

  • Doesn't work or allow anyone else to work under an elevated module without the use of stands in place

  • How did operator do lifting, moving and setting unit?

  • Correctly stores remote

  • Proper shut down of equipment

Untitled page

  • Employee Signature

  • Practical evaluator signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.