Electric Pallet Jack Operator Evaluation Form
Complete this form to assess the competency and readiness of an operator to safely and effectively use an electric pallet jack in the workplace.
Operator Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
First Name
Last Name
Pre-Operational Equipment Check Completed?
*
Yes
No
Knowledge of Controls and Safety Features
*
1
2
3
4
5
Ability to Maneuver in Confined Spaces
*
1
2
3
4
5
Safe Handling of Loads (lifting, moving, lowering)
*
1
2
3
4
5
Compliance with Workplace Safety Protocols
*
1
2
3
4
5
Performance Evaluation Table
*
Rows
Needs Improvement
Meets Expectations
Exceeds Expectations
Checks surroundings before operation
1
2
3
Uses horn/alerts appropriately
4
5
6
Maintains safe speed
7
8
9
Parks and secures equipment properly
10
11
12
Evaluator Comments / Recommendations
Submit Evaluation
Should be Empty: