ACCREDITED PROVIDER: _______________________________________
CANDIDATE: _______________________ DATE: ___________________
I.D. NUMBER:_______________________ MACHINE TYPE:___________
MACHINE MAKE:____________________ MACHINE CODE:__________
COMPANY: _________________________CAPACITY:_______________
PRE-START CHECKS (Delete items not specific to the test machine or conditions)
Personal Protective Equipment for the work environment _______________
{May include hardhats, overalls, thermal suits, goggles, earplugs as applicable}
PRE-OPERATIONAL TESTS
Total items unchecked:_____
* Omission to check any one of these items would constitute the learner/operator not being yet competent of the Pre-start checks and Pre-operational test.
THEORY TEST QUESTIONS (group )
1 __________ 4 __________
2 __________ 5 __________
3 __________
Penalties
Total items unchecked from Pre-start and Operational Assessment:
______________ x 2 = ___________________*
* Maximum 20 penalties
1. TOTAL PRE-START AND PRE-OPERATIONAL PENALTIES: ____________
PRACTICAL OPERATING ASSESSMENT
(Delete items not specific to the test machine)
| Penalties | ||
|---|---|---|
| Forks Bind on Entry/Withdrawal Forks not central under Load Load not at Heel of Forks Stack/De-stack with Mast Tilted Fails to Stack/De-stack Correctly Fails to Apply Park/Handbrake Fails to Place in Neutral Fails to Position Mast for Travel Fails to Position Forks for Travel Places Body Outside Cabin Bump Side of Course Fails to Look in Direction of Travel Selects Wrong Control direction Shunts to Stack / Un-stack Shunts to negotiate Chicane Fails to Release Park/Handbrake Fails to hold steering wheel during travel Accelerates erratically Brakes erratically Uses Controls roughly Hands on Controls | _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 5 = __________ _____________: x 10 = _________ _____________: x 5 = __________ _____________: x 10 = _________ _____________: x 1 = __________ _____________: x 1 = __________ _____________: x 5 = __________ _____________: x 10 = _________ _____________: x 1 = __________ _____________: x 3 = __________ _____________: x 5 = __________ _____________: x 5 = __________ | |
| Close down checks (park) | ||
|---|---|---|
| Fails to Place in Neutral Fails to Set Park Brake Fails to Set Mast and Forks Fails to Shut off Gas Fails to Operate Diesel Cut Out Fails to Switch Off Fails to Remove Key |
_____________: x 2 = __________ _____________: x 2 = __________ _____________: x 2 = __________ _____________: x 2 = __________ _____________: x 2 = __________ _____________: x 2 = __________ _____________: x 2 = __________ |
2. TOTAL OPERATING AND CLOSE DOWN PENALTIES _____________
TIME PENALTIES
The assessor is to complete the course to establish a fair time (minimum 15 minutes) and then add 50% to establish the maximum time to complete the operational and close down (park) assessment.
Maximum time permitted ______________ Minutes ___________ Seconds Duration of operating assessment ______ Minutes ____________Seconds3. TIME PENALTIES
(5 penalties for every 60 seconds above the maximum) ________
| 1. PRE-START AND PRE-OPERATIONAL 2. OPERATING AND CLOSE DOWN 3 TIME TOTAL PENALTIES |
________________ ________________ ________________ ________________ |
|---|
Note: The total penalties for competency should not exceed 50% of the sum of the duration of the operational and close down (park) assessment in minutes, multiplied by 6. i.e. maximum time permitted = 20 mins X 6 = 120 X 0.5 = 60
Assessor: ________________ Registration No:____________
Signature: _____________ Date:_____________
I the undersigned acknowledge that the process and results were explained to me and I accept the outcome of the assessment.
Signature/Mark of Learner: ______________
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