1. Does the provider utilize a daily, weekly, or monthly inspection form?
Yes ¨ No ¨
2. Is current, previous, and total mileage recorded at the time of the inspection?
Yes ¨ No ¨
3. Is there evidence that the vehicle fluid levels (oil, brake, power steering, transmission, coolant, and battery) are routinely inspected?
Yes ¨ No ¨
4. Is it evident what staff member completed the vehicle inspection?
Yes ¨ No ¨
5. Are the tag and registration current?
Yes ¨ No ¨
6. Are all motor vehicle operators properly licensed?
Yes ¨ No ¨
7. Are fire extinguishers in place, properly charged, and inspected annually?
Yes ¨ No ¨
8. Is there an adequate and well-supplied first aid kit?
Yes ¨ No ¨
9. Do the seatbelts function properly?
Yes ¨ No ¨
10. Does the horn operate properly?
Yes ¨ No ¨
11. Do the wipers operate properly and are the blades in good condition?
Yes ¨ No ¨
12. Are the brakes firm when depressed?
Yes ¨ No ¨
13. Does the parking brake work properly when engaged?
Yes ¨ No ¨
14. Is there a spare tire and tire changing equipment?
Yes ¨ No ¨
15. Are the door locks functional?
Yes ¨ No ¨
16. Is the interior of the vehicle clean?
Yes ¨ No ¨
17. Does the instrument panel illuminate properly?
Yes ¨ No ¨
18. Do the gauges operate properly?
Yes ¨ No ¨
19. Do the turn signal indicators operate properly when viewed inside the vehicle?
Yes ¨ No ¨
20. Does the air conditioner blow cold?
Yes ¨ No ¨
21. Does the heater blow hot?
Yes ¨ No ¨
22. Do the windows open properly?
Yes ¨ No ¨
23. Do the doors open properly?
Yes ¨ No ¨
24. Is the exterior of the vehicle clean and not in need of repair?
Yes ¨ No ¨
25. If the vehicle is damaged, has an assessment action to repair been done?
Yes ¨ No ¨ N/A ¨
26. Do the headlights operate properly?
Yes ¨ No ¨
27. Do the turn signal indicators blink both front and rear?
Yes ¨ No ¨
28. Do the brake lights illuminate when the brake pedal is depressed?
Yes ¨ No ¨
29. Are the tires in good repair?
Yes ¨ No ¨
30. Does the vehicle have an audio warning system for when it is backing up?
Yes ¨ No ¨
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Comments:
______
Printed Name of Individual Completing Form Date Completed
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