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Driver Name
*
First
Last
Date/Time
Date
*
Time:
*
Nurse
Nurse Phone number
*
1. Exterior Inspection
Vehicle Make/Model:
*
License Plate:
*
Odometer Reading:
*
1. Exterior Inspection
1. Exterior Inspection
Front Left
Front Right
Rear Left
Rear Right
Lights & Indicators (Check headlights, brake lights, turn signals, reverse lights):
Headlights
Brake Lights
Turn Signals (Left/Right)
Hazard Lights
Reverse Lights
Windows and Mirrors (Check for cracks, cleanliness, and functionality):
Windshield
Side Mirrors (Left/Right)
Rearview Mirror
Window Operation
Windshield Wipers (Check for damage and adequate fluid level):
Wiper Blades
Windshield Washer Fluid Level
Body Condition
Front Bumper
Rear Bumper
Sides/Body Panels
2. Under the Hood
Under the Hood
Engine Oil
Coolant Level
Battery Check
3. Interior Inspection
Dashboard Warning Lights (Check if any warning lights are on):
Check Engine Light
Oil Pressure
Battery
Seats and Seatbelts (Ensure seat belts are functioning and seats are secure):
Seatbelts (All Positions)
Driver’s Seat Secure
Passenger Seats Secure
Air Conditioning/Heating (Test to ensure system works):
A/C
Heater
Parking Brake (Ensure parking brake is functioning):
Parking Brake Working
Driver’s Notes/Observations:
Sign Name
Submit
