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Environmental Health & Safety
E H & S
TEL NO: (818) 677-2401
FAX NO: (818) 677-5853
MAIL DROP: 8284
Powered Cart/Low Speed Vehicle Safety Training
Employee & Supervisor Training Certification
I. Employee Information:
Name:
Employee/Student ID:
Title:
Trainer:
Title:
Date of Training:
LINE
II. SUBJECTS COVERED: (Please check Yes or No)
Prior to operating a powered cart or LSV on the CSUN campus, drivers must review the Powered Cart/Low Speed Vehicle Safety Program and complete a brief safety-training program administered by their supervisor. At the completion of training, confirm the Powered Cart/Low Speed Vehicle Safety Program subjects covered by checking the appropriate box below. Note: this training is in addition to the Defensive Driving class required for all drivers of state vehicles. Both of these courses are required every 4 years.
•
Ensure that employee has fulfilled the Training requirements of the Powered Cart/Low Speed Vehicle Safety Program.
Yes
No
•
Explain the Purpose of the program Powered Cart/Low Speed Vehicle Safety Program.
Yes
No
•
Yes
No
•
Review the Pre-Trip Safety Inspection requirements.
Yes
No
•
Review the basic operating instructions for the cart or LSV with the employee.
Yes
No
•
Yes
No
•
Yes
No
Please keep a copy of this form in your files.
   
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Training Certification
Employee: I hereby acknowledge that I have received training on the subjects indicated above.
Employee Signature: ________________________________
Date:  ___________
Supervisor:  I certify the above employee has received training in the safe operation of powered carts or LSV. I am satisfied that he/she fully understands their responsibilities as a powered cart or LSV operator.
Supervisor Signature: _______________________________
Date:  ___________
Supervisor Print Name:
Original: Department Files - Copy: EH&S (Mail Drop 8284)
Revision date: Jan 2004    Rev. # 3.0