VEHICLE SAFETY INSPECTION
Instructions: At 12‐month intervals, the licensee shall provide this form to the garage, dealership, auto repair shop or other certified
vehicle service facility to be completed by an ASE accredited technician. An alternate form may be used as long as all of the required
inspection points are addressed. The licensee shall submit the completed form to the Licensing Specialist.
Facility Name
License Number
Registered Family
Certified Family
Certified Center
Regulated Subsidy
Vehicle – Year
Make
Model
Odometer Reading
License Plate Number
Inspecting Company or Agency Name
Inspector Name
Telephone Number
Address
City
State
Zip Code
VEHICLE INSPECTION CHECKLIST
Item
Pass Repair/Replace
Item
Pass Repair/Replace
BRAKES
SAFETY FEATURES
1. Failure Indicator Light
20. Turn Signals operational
2. System Integrity
21. Head Lights
3. Pedal Reserve
22. Tail Lights
4. Disc/Drum Rotation
23. Brake Lights
5. Hoses and Assembly
24. Horn
25. Windows/Windshield (cracks/chips)
SUSPENSION
6. Shock Absorbers/Struts
26. Front Seat Safety Belts condition
7. Springs
27. Back Seat Safety Belts condition
8. Shackles
28. Door Locks operational
9. Modifications
Left Right
Left Right
TIRES – FRONT
29. Tread Depth
STEERING
10. Lash
30. Matching
11. Free Turning
31. Condition
12. Linkage Play
32. Proper Inflation
13. Power System
TIRES ‐ REAR
33. Tread Depth
EXHAUST SYSTEM
14. Leaks
34. Matching
15. Legal Muffler
35. Condition
16. Tailpipe
36. Proper Inflation
WIPERS/WIPER BLADES
17. Wipers operational
18. Blades contact
19. Blades condition
Brief Comments – Refer to Item Number
SIGNATURE ‐ Inspector
DATE – Inspection
Oregon Department of Education • Early Learning Division • Office of Child Care •
LIC‐321 8/2017
Distribution: Original – Licensing File
Yellow – Facility File