"Vehicle Inspection Record Form - Pre- Mid- Post- and Weekly" - Kansas

Vehicle Inspection Record Form - Pre- Mid- Post- and Weekly is a legal document that was released by the Kansas Department of Transportation - a government authority operating within Kansas.

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Download "Vehicle Inspection Record Form - Pre- Mid- Post- and Weekly" - Kansas

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Please fill out this daily record completely, using a new sheet for each day/vehicle in service. When completing, DO NOT use a
dash or check mark in the boxes – use your initials. Inspection record will be invalid if you don’t use your initials. If you are the
Mid-Shift Driver, please initial all items in the Pre-Trip columns under the Pre-Trip driver’s initials. Report any defects to your
vehicle immediately to your supervisor or manager before taking it on the road. If you have questions, consult with your
supervisor or manager. Keep on file for 90 days, unless the vehicle is involved an incident or accident – keep those permanently
on file by attaching them to the copy of the incident or police report.
INITIALS
PRE-TRIP: INTERIOR
COMMENT
Seat Belts & Safety Restraints
Vehicle #:
______________
Tablet #: __________
– Check for damage, and that
all belts and restraints are
Vehicle Location: ________________________________
available, functional, and in
good condition. Check
Day of the week:
Su M T W Th F Sa
restraints and passenger belts
for any fraying or wear to belts.
Date: _________________________________________
Cleanliness/Items Secured –
Check for cleanliness and that
Pre-Trip Odometer: ______________________________
all items are secured (e.g.
assistive devices, scrapers,
Post-Trip Odometer: _____________________________
spray cleaners, etc.) Ensure the
driver’s area is clean and all
items are secured.
Emergency Equipment –
Check fire extinguisher (fully
charged, on board, and secure),
PRE-TRIP (and SHIFT CHANGE) ITEMS
web cutter, first aid/bloodborne
pathogen kit(s), triangle warning
INITIALS
PRE-TRIP: EXTERIOR
COMMENT
kit, cameras and drag blanket (if
Exterior Body - Check for
applicable).
damage; clear any debris.
Emergency Door, Roof Hatch,
Make sure all doors open and
Windows, Horn – Check that
close properly, and are
all are accessible and in working
unlocked and accessible.
order. Make sure the rear door
Windows & Mirrors – Verify
buzzer works properly (if
windows and mirrors are not
applicable) – the buzzer must
cracked or broken.
work when the key is engaged
Wipers/Blades – ensure blades
and the back door is open.
are not cracked or torn, and in
Technology – ensure devices
good working order.
are in good working order.
Lights & Reflectors – Turn on
Climate Control – check
headlights and four-way
functionality of heating and air
flashers, make sure all lamps
conditioning units.
illuminate. Check high and low
Warning Lights/Gauge Levels
beams on the headlights.
- Visually check all gauges and
Check to see reflectors are in
report any warning lights.
good condition. Brake lights
Accident Response Kit –
checked by 2nd person.
calling tree and forms for
Tires – check the tread depth,
reporting accidents are in place
pressure, and overall condition.
(if applicable).
No punctures, cracks, tread
Wheelchair Securement –
separations; adequate tread
Mechanisms are in place and
depth prescribed by
functioning, tracks are clear of
manufacturer. Check rims for
debris, and adequate number of
missing lug nuts, broken stubs.
devices/seatbelts are present.
Undercarriage – Look for
Wheelchair Lift/Ramp – Cycle
water, oil, gas, transmission, or
lift, paying attention to the
other fluid leaks under the
wheelchair securement system.
vehicle. If leak is detected,
Double check safety barriers.
report it immediately.
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t<>z
Please fill out this daily record completely, using a new sheet for each day/vehicle in service. When completing, DO NOT use a
dash or check mark in the boxes – use your initials. Inspection record will be invalid if you don’t use your initials. If you are the
Mid-Shift Driver, please initial all items in the Pre-Trip columns under the Pre-Trip driver’s initials. Report any defects to your
vehicle immediately to your supervisor or manager before taking it on the road. If you have questions, consult with your
supervisor or manager. Keep on file for 90 days, unless the vehicle is involved an incident or accident – keep those permanently
on file by attaching them to the copy of the incident or police report.
INITIALS
PRE-TRIP: INTERIOR
COMMENT
Seat Belts & Safety Restraints
Vehicle #:
______________
Tablet #: __________
– Check for damage, and that
all belts and restraints are
Vehicle Location: ________________________________
available, functional, and in
good condition. Check
Day of the week:
Su M T W Th F Sa
restraints and passenger belts
for any fraying or wear to belts.
Date: _________________________________________
Cleanliness/Items Secured –
Check for cleanliness and that
Pre-Trip Odometer: ______________________________
all items are secured (e.g.
assistive devices, scrapers,
Post-Trip Odometer: _____________________________
spray cleaners, etc.) Ensure the
driver’s area is clean and all
items are secured.
Emergency Equipment –
Check fire extinguisher (fully
charged, on board, and secure),
PRE-TRIP (and SHIFT CHANGE) ITEMS
web cutter, first aid/bloodborne
pathogen kit(s), triangle warning
INITIALS
PRE-TRIP: EXTERIOR
COMMENT
kit, cameras and drag blanket (if
Exterior Body - Check for
applicable).
damage; clear any debris.
Emergency Door, Roof Hatch,
Make sure all doors open and
Windows, Horn – Check that
close properly, and are
all are accessible and in working
unlocked and accessible.
order. Make sure the rear door
Windows & Mirrors – Verify
buzzer works properly (if
windows and mirrors are not
applicable) – the buzzer must
cracked or broken.
work when the key is engaged
Wipers/Blades – ensure blades
and the back door is open.
are not cracked or torn, and in
Technology – ensure devices
good working order.
are in good working order.
Lights & Reflectors – Turn on
Climate Control – check
headlights and four-way
functionality of heating and air
flashers, make sure all lamps
conditioning units.
illuminate. Check high and low
Warning Lights/Gauge Levels
beams on the headlights.
- Visually check all gauges and
Check to see reflectors are in
report any warning lights.
good condition. Brake lights
Accident Response Kit –
checked by 2nd person.
calling tree and forms for
Tires – check the tread depth,
reporting accidents are in place
pressure, and overall condition.
(if applicable).
No punctures, cracks, tread
Wheelchair Securement –
separations; adequate tread
Mechanisms are in place and
depth prescribed by
functioning, tracks are clear of
manufacturer. Check rims for
debris, and adequate number of
missing lug nuts, broken stubs.
devices/seatbelts are present.
Undercarriage – Look for
Wheelchair Lift/Ramp – Cycle
water, oil, gas, transmission, or
lift, paying attention to the
other fluid leaks under the
wheelchair securement system.
vehicle. If leak is detected,
Double check safety barriers.
report it immediately.
______________________________________________
POST-TRIP ITEMS
SIGNATURES
INITIALS
POST-TRIP
COMMENT
Properly set brake and vehicle
securement.
I have personally conducted the pre-trip inspection for this vehicle and
All windows/hatches are
have found it to be in the condition stated above.
secured.
No passengers or personal
______________________________________
property remains in the vehicle.
Pre-Trip Driver’s Signature
No signs of damage to the
interior or exterior of the vehicle.
Emergency Equipment
I have personally conducted the mid-shift inspection for this vehicle and
Brakes
have found it to be in the condition stated above.
Steering
Lighting Devices/Reflectors
Tires
______________________________________
Horn
Mid-Shift Driver’s Signature (if vehicle changed
Wipers
driver mid-day)
Mirrors
Wheels & Rims
Reason for change in drivers:
Shift change
WEEKLY ITEMS
Accident/Incident
Day of the week:
Su M T W Th F Sa
Other: ____________________________
Date: _________________________________________
INITIALS
POST-TRIP
COMMENT
I have personally conducted the post-trip inspection for this vehicle and
Fluids – check/fill each:
have found it to be in the condition stated above.
Oil
Radiator Level
_____________________________________
Windshield Washer Fluid
Power Steering Fluid
Post-Trip Driver’s Signature
Brake Fluid
_______________________________
________
Transmission Fluid
Battery (if not maint-free)
Supervisor’s or Manager’s Signature
Date
Battery – check cable
connections are tight and clear
of corrosion.
Belts – check that they are not
Maintenance assessment:
cracked/worn.
Hoses – Check for leaks; if
Condition of the above vehicle is satisfactory.
found, report immediately.
Make sure hoses are not
Above defects have been corrected.
spongy/cracked.
Exhaust - Check muffler for
Date of repair: ___________________
looseness.
Vehicle removed from service for necessary
repair(s).
Date removed: ____________________
Explanation of any items listed above:
_____________________________________________
_____________________________________________
______________________________
_______
______________________________________________
Maintenance Supervisor Signature
Date
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