SENIOR CENTER VEHICLE # 1 VEHICLE # 2 VEHICLE # 3 VEHICLE # 4 Comments / Findings & DATE & DATE & DATE & DATE Critical Non Critical No Findings    Corrective Action Description INTERIOR Starter (Engine Starts) Brakes (Working Properly) Parking Brake (Working Properly) Steering Mechanism Heater Working Properly A/C Working Properly Front Defrost Mechanism Working Properly Rear Defrost Mechanism Working Properly Interior Lights Working Properly Odometer Working Properly Speedometer Working Properly Gas Working Properly Temperature Gauge Working Properly Horn Working Properly RESTRAINT SYSTEMS Wheel Chair Belts Passenger Seat Belts Wheel Chair Restraints Driver’s Seat Belt LIFT/RAMP Cycle Lift Lift Mechanism Working Properly Ramp Folds/Unfolds Ramp Locking Device Functional SAFETY Emergency Phone Contact List Vehicle Registration First Aid/Bodily Fluid Kit Fire Extinguisher Proof of Insurance Emergency Triangle Kit Working Flashlight If Provider has more than 4 vehicles, add additional Sheets
SENIOR CENTER VEHICLE # 1 & DATE VEHICLE # 2 & DATE VEHICLE # 3 & DATE VEHICLE # 4 & DATE Comments / Findings  Critical  Non Critical  No Findings Corrective Action Description INTERIOR Starter (Engine Starts) Brakes (Working Properly) Parking Brake (Working Properly) Steering Mechanism Heater Working Properly A/C Working Properly Front Defrost Mechanism Working Properly Rear Defrost Mechanism Working Properly Interior Lights Working Properly Odometer Working Properly Speedometer Working Properly Gas Working Properly Temperature Gauge Working Properly Horn Working Properly RESTRAINT SYSTEMS Wheel Chair Belts Passenger Seat Belts Wheel Chair Restraints Driver’s Seat Belt LIFT/RAMP Cycle Lift Lift Mechanism Working Properly Ramp Folds/Unfolds Ramp Locking Device Functional SAFETY Emergency Phone Contact List Vehicle Registration First Aid/Bodily Fluid Kit Fire Extinguisher Proof of Insurance Emergency Triangle Kit Working Flashlight If Provider has more than 4 vehicles, add additional Sheets
CO_Form_2_Vehicle_Inventory_Inspection_Checklist.docx