Department of Public Safety | Ohio.gov



OHIO DEPARTMENT OF PUBLIC SAFETYDIVISION OF EMERGENCY MEDICAL SERVICESPERIODIC MECHANICAL SAFETY REPORTSERVICE NAME FORMTEXT ?????DATE OF INSPECTION FORMTEXT ?????VEHICLE MAKE FORMTEXT ?????MODEL FORMTEXT ?????VEHICLE DECAL NUMBER FORMTEXT ?????SERVICE VEHICLE NUMBER FORMTEXT ?????VEHICLE IDENTIFICATION NUMBER FORMTEXT ?????CURRENT MILEAGE FORMTEXT ?????DATE OF LAST INSPECTION FORMTEXT ????? FORMCHECKBOX Ambulance FORMCHECKBOX MoICU FORMCHECKBOX Non-Transport Vehicle FORMCHECKBOX AmbulettePlease mark each item listed below as either passed or failed. All failed items must have a date indicating when the item was corrected and include supporting documentation.FRONT DRIVER / PASSENGER COMPARTMENTPASSEDFAILEDDATE CORRECTEDSeats secure to floor and in safe condition FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Safety belts operational and free of visible damage FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Floor intact / free of holes FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Doors / Door panels operational without breach FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Compartment is clean / free of debris FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Instruments / gauges in proper working order FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Heat / AC operational FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Windows without breach, unobstructed, operational FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Windshield wipers and washer operational FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Mirrors, driver and passenger side, without breach FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Power steering operational FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Steering shaft secure – No excessive play FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Horn operational / audible FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Siren operational / audible FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Airbags FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Emergency / parking brake operational FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Audible backup alarm operational FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comments FORMTEXT ?????TIRES / WHEELS PASSEDFAILEDDATE CORRECTEDTires match and are correct sizeRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Tire PressureRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Tire tread condition min 1/16th inchRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Unusual tire wear tread / sidewallRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Valve StemsRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Rims / Wheels free of damageRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Tires have full range of motionRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Rack–and-pinion, linkage and boots FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Control arms, bushings, and ball joints FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Sway bars, links, and bushings FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Springs FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Shocks and struts FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Power steering pump FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comments FORMTEXT ?????BRAKES PASSEDFAILEDDATE CORRECTEDRotors and drumsRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Brake pads and shoesRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Brake lines, hoses, and fittingsRF LF RR LR FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Master cylinder and booster FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????ABS working properly FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comments FORMTEXT ?????BODY AND FRAME (No excessive rust, breach to inside of vehicle or integrity of vehicle)PASSEDFAILEDDATE CORRECTEDProtruding metal on vehicle body FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Bumpers FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Hood FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Fenders FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Frame FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comments FORMTEXT ?????FUEL SYSTEMPASSEDFAILEDDATE CORRECTEDFuel pump FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Hoses & fittings FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Fuel lines FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Fuel tank FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Brackets & straps FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comments FORMTEXT ?????EXHAUST SYSTEMPASSEDFAILEDDATE CORRECTEDManifold FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Pipes & fittings FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Muffler FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Bracket / hanger FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Exhaust pipe / integrity FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Engine emissions check (if applicable) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Comments FORMTEXT ?????CERTIFIED MECHANIC VERIFICATIONI attest I inspected this vehicle and completed this form. FORMCHECKBOX This vehicle passed inspection and is safe and roadworthy at the time of inspection. FORMCHECKBOX The vehicle has failed inspection. I have made the service aware of all failed items identified during the inspection that require correction.NAME FORMTEXT ?????SIGNATUREXDATE FORMTEXT ?????TITLE FORMTEXT ?????CERTIFICATION / QUALIFICATIONS FORMTEXT ?????EMPLOYER’S NAME FORMTEXT ?????PHONE NUMBER FORMTEXT ?????SERVICE REPRESENTATIVEI attest that this inspection was conducted in accordance with the requirements set forth in Section 4766 of the Ohio Administrative Code (O.A.C.), and that all failed items identified during the inspection have been corrected prior to placing the vehicle back into service.NAME FORMTEXT ?????TITLE FORMTEXT ?????SIGNATUREXDATE FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download