Dcf-F - Vehicle Safety Inspection - Wisconsin
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1DEPARTMENT OF CHILDREN AND FAMILIES
STATE OF WISCONSIN
Division of Early Care and Education
DCF-F (CFS-52) (R. 12/2008)
VEHICLE SAFETY INSPECTION
Use of form: Use of this form is mandatory to comply with DCF 52.47(6)(a)1., DCF 57.12(5), DCF 250.08(4)(b), DCF 251.08(7)(a), and DCF
252.09(3)(b). Failure to comply may result in issuance of a noncompliance statement.
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.
Name – Facility
Type
Family Child Care
Group Child Care
RCC for Children and Youth
Day Camp
Group Foster Home
Vehicle – Year
Make
Model
Color
Odometer Reading
License Plate Number
Name – Inspecting Company or Agency
Name – Inspector
Telephone Number
Address
City
State
Zip Code
VEHICLE INSPECTION CHECKLIST
Repair /
Repair /
Item
Pass
Item
Pass
Replace
Replace
BRAKES
SAFETY FEATURES
1. Failure indicator light
17. Turn signals operational
2. System integrity
18. Head lights
3. Pedal reserve
19. Tail lights
4. Disc / drum condition
20. Brake lights
5. Hoses and assembly
21. Horn
SUSPENSION
22. Windows / Windshield (cracks / chips)
6. Shock absorbers / struts
23. Front seat safety belts condition
7. Springs
24. Back seat safety belts condition
8. Shackles
25. Door locks operational
WIPERS / WIPER BLADES
9. Modifications
STEERING
26. Wipers operational
10. Lash
27. Blades contact
11. Free turning
28. Blades condition
TIRES – FRONT
12. Linkage play
Lft
Rt
Lft
Rt
13. Power system
29. Tread depth
EXHAUST SYSTEM
30. Matching
14. Leaks
31. Condition
TIRES – REAR
15. Legal muffler
Lft
Rt
Lft
Rt
16. Tailpipe
32. Tread depth
33. Matching
34. Condition
Brief Comments – Refer to Item Number
SIGNATURE – Inspector
Date – Inspection
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