Form Wh-514a - Vehicle Mechanical Inspection Report For Transportation Subject To Department Of Labor Safety Standards
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1
2U.S. Department of Labor
Vehicle Mechanical Inspection Report for Transportation
Wage and Hour Division
Subject to Department of Labor Safety Standards
NAME OF APPLICANT
OMB NO: 1235-0016
Expires: 11/30/2018
ADDRESS
STATE
ZIP CODE
IMPORTANT:
The Migrant and Seasonal Agricultural Worker Protection Act requires that farm labor contractors subject to this law who transport any migrant
and seasonal agricultural workers for agricultural employment obtain from the U.S. Department of Labor a certificate of registration. Applicants
for a certificate of registration must produce evidence that the vehicles they use for this purpose meet Department of Labor requirements.
Provided below is a list of major items which should be checked. On the reverse side of this form is a brief summary of the Department of Labor
standards for each of these items. A check (✓) should be placed adjacent to each item that meets these minimum standards. In those instances
where an item does not meet these standards, necessary repairs must be completed before the transportation of migrant and seasonal
agricultural workers will be authorized. This form must be properly completed and signed, certifying that the vehicle meets Department of Labor
requirements. This inspection must be performed by an independent inspection company not affiliated with the applicant.
This form (WH-514a) is to be used for the inspection of any passenger car or station wagon regardless of the distance traveled and for other
vehicles used to transport migrant and seasonal agricultural workers (except day-haul operations) for distances of seventy five (75) miles or less.
Vehicles used in day-haul operations and those used to transport workers for more than 75 miles are subject to Department of Transportation
standards. Form WH-514 must be used for inspection of such vehicles.
If the farm labor contractor possesses a valid current state vehicle safety inspection sticker from the jurisdiction in which the vehicle is registered,
the items listed below need not be checked. However, in the Remarks section, the farm labor contractor must identify the state where the
inspection was performed, list the appropriate state vehicle safety inspection number and license tag number and then sign and date the form.
Serial or Motor No.: ___________________________Registration No.: _____________ State: ________ License Plate No.: __________
Make: ___________________Model: _________________________ Year: ________ Color: ________ No. of Seats: ______________
Truck
Tractor
Semitrailer
Full Trailer
Bus
Passenger Car
Station Wagon
Van
This vehicle is used to pull a trailer: Yes
No
LIGHTING DEVICES
PASSENGER COMPARTMENT
(15) Steering
(1) Headlights
(8) Windshield/windows
(16) Horn
(2) Stop lights
(9) Ventilation
PARTS AND ACCESSORIES
(3) Tail lights
(10) Seats
(17) Windshield wipers
(4) Back-up lights
(11) Door-handles / latches
(18) Rear vision mirrors
EMERGENCY EQUIPMENT
(5) Turn signals
(19) Fuel system
BRAKES
(12) Hazard warning lights
(20) Exhaust system
(6) Service (foot)
(13) Tires
(7) Parking brake
(14) Side mirrors
REMARKS:
AUTHORIZED INSPECTION NUMBER (IF APPLICABLE)
EXPIRATION DATE OF INSPECTION NUMBER (IF APPLICABLE)
NAME OF SHOP (GARAGE)
ADDRESS OF SHOP (GARAGE)
TELEPHONE NUMBER
DATE OF INSPECTION
NAME OF INSPECTOR
TITLE OF INSPECTOR
PUBLIC BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
the Administrator, U.S. Department of Labor, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
FORM WH-514a
REV 11/2015
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