WEEKLY PRE-TRIP INSPECTION REPORT
PROVIDER NAME __________________________________________
PROVIDER # ______________________
MONTH_____________
YEAR, MAKE & MODEL ___________________________________
LICENSE PLATE ___________________
YEAR_______________
Date
Date
Date
Date
Date
Date
Date
Items to inspect on each trip
Windows and mirrors are clean and free of cracks/breaks?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Tie downs, if applicable, are present and function properly?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Seat belts function properly?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Wheelchair Lift, if applicable, is operating properly?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
All lights, including headlights and turn indicators, function properly?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
First Aid kit is in vehicle?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Fire extinguisher is in vehicle and indicates as "good"?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
The horn is working properly?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Windshield wipers are working correctly?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Tread on all four tires is sufficient?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Test service brakes?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
NON MEDICAL TRANSPORTATION- PER MILE - DOCUMENTATION – Cuyahoga County
Date
Pick Up
Odometer
Drop Off
Odometer End
Total Miles
Names of All
Time
Start
Time
Driven
Passengers
SIGNATURE:
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SIGNATURE:
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______
SIGNATURE:
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______
SIGNATURE:
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