Vehicle Safety Inspection, DCF-F-CFS52



Child Welfare Vehicle Safety InspectionUse of form: Use of this form is mandatory to comply with DCF 52.47(6)(a)1., DCF 57.12(5). Failure to comply may result in issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].Instructions: At 12-month intervals, the licensee shall provide this form to the garage, dealership, or auto repair shop to be completed by the inspector upon completion of the vehicle inspection. The licensee shall submit the completed form to the Licensing Specialist.Facility Name FORMTEXT ?????Facility ID FORMTEXT ?????Type FORMCHECKBOX Residential Care Center for Children and Youth FORMCHECKBOX Group Home FORMCHECKBOX Shelter Care FacilityVehicle – Year FORMTEXT ????Make FORMTEXT ?????Model FORMTEXT ?????Color FORMTEXT ?????Odometer Reading FORMTEXT ?????License Plate Number FORMTEXT ?????Name of Inspecting Company or Agency FORMTEXT ?????Inspector Full Name FORMTEXT ?????Telephone Number FORMTEXT ?????Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ??Zip Code FORMTEXT ?????VEHICLE INSPECTION CHECKLISTItemPassRepair /ReplaceItemPassRepair /ReplaceBRAKES FORMCHECKBOX FORMCHECKBOX SAFETY FEATURES FORMCHECKBOX FORMCHECKBOX 1.Failure indicator light FORMCHECKBOX FORMCHECKBOX 17.Turn signals operational FORMCHECKBOX FORMCHECKBOX 2.System integrity FORMCHECKBOX FORMCHECKBOX 18.Head lights FORMCHECKBOX FORMCHECKBOX 3.Pedal reserve FORMCHECKBOX FORMCHECKBOX 19.Tail lights FORMCHECKBOX FORMCHECKBOX 4.Disc / drum condition FORMCHECKBOX FORMCHECKBOX 20.Brake lights FORMCHECKBOX FORMCHECKBOX 5.Hoses and assembly FORMCHECKBOX FORMCHECKBOX 21.Horn FORMCHECKBOX FORMCHECKBOX SUSPENSION FORMCHECKBOX FORMCHECKBOX 22.Windows / Windshield (cracks / chips) FORMCHECKBOX FORMCHECKBOX 6.Shock absorbers / struts FORMCHECKBOX FORMCHECKBOX 23.Front seat safety belts condition FORMCHECKBOX FORMCHECKBOX 7.Springs FORMCHECKBOX FORMCHECKBOX 24.Back seat safety belts condition FORMCHECKBOX FORMCHECKBOX 8.Shackles FORMCHECKBOX FORMCHECKBOX 25.Door locks operational FORMCHECKBOX FORMCHECKBOX 9.Modifications FORMCHECKBOX FORMCHECKBOX WIPERS / WIPER BLADES FORMCHECKBOX FORMCHECKBOX STEERING FORMCHECKBOX FORMCHECKBOX 26.Wipers operational FORMCHECKBOX FORMCHECKBOX 10.Lash FORMCHECKBOX FORMCHECKBOX 27.Blades contact FORMCHECKBOX FORMCHECKBOX 11.Free turning FORMCHECKBOX FORMCHECKBOX 28.Blades condition FORMCHECKBOX FORMCHECKBOX 12.Linkage play FORMCHECKBOX FORMCHECKBOX TIRES – FRONTLftRtLftRt13.Power system FORMCHECKBOX FORMCHECKBOX 29.Tread depth FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX EXHAUST SYSTEM FORMCHECKBOX FORMCHECKBOX 30.Matching FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 14.Leaks FORMCHECKBOX FORMCHECKBOX 31.Condition FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 15.Legal muffler FORMCHECKBOX FORMCHECKBOX TIRES – REARLftRtLftRt16.Tailpipe FORMCHECKBOX FORMCHECKBOX 32.Tread depth FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 33.Matching FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 34.Condition FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brief Comments – Refer to Item Number FORMTEXT ?????Inspector SIGNATUREInspection Date (mm/dd/yyyy) FORMTEXT ????? ................
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