Monthly Motorized Pallet Jack Inspection Form - Waukesha County ...

Waukesha County Technical College
POWERED INDUSTRIAL TRUCK INSPECTION CHECKLIST
MOTORIZED PALLET JACK
Truck ID #: Department: Hour meter Reading:
Motorized Pallet Jacks are required to be inspected prior to being placed into service for the first time on a
given shift. It will be the responsibility of the operator to conduct and document the inspection.
The inspection shall be documented by the operator initializing the box corresponding to the date and shift of
when the inspection was completed. The top portion is for day-shift inspections and the bottom is for night-shift
inspections. Those days and shifts when the motorized pallet jack is not used will be left blank.
Month:
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 31
Turn in inspection sheet to Department Manager / Supervisor at
the end of each month.
Deficiencies shall be recorded in the Deficiency Log below. If a deficiency is identified the motorized pallet jack
should be removed from service until the deficiency has been corrected or the motorized pallet jack has been
deemed safe to operate.
Date
Identified
Operator
Deficiency Log
Description of Deficiency
Date
Corrected
Reference the back of this sheet for directions on completing the inspections and the items to be inspected.

Directions for Completing the Motorized Pallet Jack Inspection
1. The motorized pallet jack is to be inspected at the beginning of each shift that it will be in service.
The inspection must be completed prior to it being operated on the shift.
2. The operator will inspect the motorized pallet jack to insure the components listed below are in
proper operating condition.
Key-Off Inspection
Forks
Battery
Hand guards
Nameplate / lifting capacity tag
Key-On Inspection
Hour meter gauge
Battery indicator
Steering
Brakes
Check the drive operations
Horn
When conducting the inspection, the operator should focus on identifying hazards which may include
but are not limited to dents, cracks, leaks, broken and/or malfunctioning components or any other
condition creating a hazard to the operator or anyone in the immediate area of where the motorized
pallet jack is being operated. If you have any questions contact you Department Manager /
Supervisor.
3. Inspect the components listed in the Key-Off Inspection list to insure they are all in proper working
condition.
4. Inspect the components listed in the Key-On Inspection list to insure they are all in proper working
condition.
5. If NO deficiencies are identified, then document the inspection by initialing the box corresponding
to the date / time of the inspection.
6. If a deficiency is identified, the following action shall be taken:
a. Motorized pallet jack should immediately be taken out of service.
b. Notify your supervisor of the situation.
c. Record the deficiency in the Deficiency Log.
d. The motorized pallet jack will be removed from service until the deficiency has been corrected
or the motorized pallet jack has been deemed safe to operate by the Department Manager /
Supervisor.
7. The inspection form shall be handed in to the Department Manager / Supervisor at the end of
each month.