CCFR 10.9 (4/17)
Charlton County Fire & Res
c
ue
The Desire to
Serve
The Courage to
Act
The Ability to
Perform
Personal Vehicle Safety Checklist
Date of Review:
Member Name: Vehicle Make/Model/Year: License Plate #:
Driver’s License #: Restrictions: Yes No If “yes”, describe:
Required
Documents
Current Registration: Yes No Current State Inspection: Yes No N/A
Proof of Insurance: Yes No Insurance Company: Expiration Date:
Lights & Siren Permit: Yes No N/A Courtesy Lights Permit: Yes No N/A
VEHICLE CONDITION
Tires
Left Front Good tread: *Fair tread: **Poor tread:
Right Front Good tread: *Fair tread: **Poor tread:
Left Rear Good tread: *Fair tread: **Poor tread:
Right Rear Good tread: *Fair tread: **Poor tread:
Brakes
Stopping Distance Good *Fair **Poor
Lights Left
Right
Headlights:
High beam YES **NO YES **NO
Low beam YES **NO YES **NO
Turn Signals:
Front YES **NO YES **NO
Rear YES **NO YES **NO
Tail Lights YES **NO YES **NO
Brake Lights YES **NO YES **NO
Back-up Lights YES **NO YES **NO
NOTE:
Any * indicates a need to have
vehicle checked by a qualified
mechanic
Any ** needs immediate repair or
replacement
CCFR 10.9 (4/17)
Body
Any damage: Yes No If “yes”, describe:
Exhaust System Good *Fair **Poor
Glass Front
Rear
Window Good: YES NO Good: YES NO Describe damage:
Left Side Good: YES NO Good: YES NO Describe damage:
Right Side Good: YES NO Good: YES NO Describe damage:
Accessories
Wipers Operational: YES **NO
Blades Condition Good *Fair **Poor
Warning/
Courtesy Lights Operational: YES **NO Meets State Requirements: YES **NO
Horn Operational: YES **NO
Mirrors YES **NO
Additional Comments
Repairs Needed/Completed Data (Give to operator to document completed repairs. Operator is to return form to Fire Chief.)
Repairs Needed:
Repairs Comments:
Repairs Completed By (signature): Date:
The completion of this checklist indicates that we have undertaken a limited survey of your vehicle. The findings of this document are limited to certain conditions that were observed and evaluated at the time of the
survey. This survey or the completed checklist is not a substitute for any mechanical inspection made by a qualified vehicle technician. Any observations or recommendations enumerated in this document do not
constitute a safety inspection and in no
way supplant your duty to maintain your vehicle in a safe operating condition. Completion of any or all of the recommendations contained in this document does not assure
that every hazard has been adequately controlled or that no other hazards exist. By completion of this checklist we do
NOT warrant that any or all vehicles or equipment are safe or in compliance with any law, rule,
regulation or ordinance.
NOTE:
Any * indicates a need to
have vehicle checked by a
qualified mechanic
Any ** needs immediate
repair or replacement
CCFR 10.9 (4/17)
Instructions for Use
This safety checklist is provided for you to conduct a basic safety survey of your organization’s members’ personally owned vehicles. This is not intended to
be a mechanical inspection and is not a substitute for one. This checklist reviews some of the basic components that should be well maintained to provide a
vehicle that is in safe working order. Anyone with basic knowledge of a vehicle’s operating components should be able to conduct the survey. This survey
should be completed on an
annual basis.
Items to Look For
Required Documents: Verify that listed documents are present, current, and appropriate.
Tires: Tires should be checked to determine if there are any obvious conditions that would make them unsafe, e.g., cuts, bulges, uneven tread wear,
questionable inflation level and inadequate tread depth. Tires should generally be of the same size and style. Any questionable items should be evaluated
and repaired by a qualified automotive technician.
Lights: All lights should be checked to determine if they operate properly, have the proper lens covering, are clearly visible, and are properly adjusted. Any
questionable items should be evaluated and repaired by a qualified automotive technician.
Brakes: Brakes should be checked to determine stopping distance. If stopping distance appears to be inadequate brakes must be checked by a qualified
mechanic. Stopping distance will be tested again before vehicle will be approved for use.
Body: The body of the vehicle should be checked to determine that all required components are on the vehicle e.g. fenders, hood, bumpers, etc. Any
damaged component should be checked to determine if it will interfere with the safe operation of the vehicle or present a safety hazard for pedestrians or
other vehicles.
The exhaust system should be checked to determine if it is operating properly. Visually check to determine if all parts are present and that they are safely
attached to the vehicle. Operationally, the exhaust system may be checked by briefly holding a pliable object (such as a rag) over the end of the exhaust
pipe to obstruct the flow of exhaust. If back pressure is felt on the object while it is held in place and no hissing or whistling is heard in other parts of the
exhaust system, it is reasonable
to assume that the exhaust system is working. However if little or no pressure is felt on the object blocking the exhaust
pipe and/or exhaust gases can be heard escaping from other parts of the system, the vehicle should be further examined by a qualified technician.
Caution
should be used when checking exhaust systems, as exhaust gases and the system components may be very hot and can cause injury.
Glass: All glass should be checked to determine if it is in good condition, free of chips, cracks, and breaks. Windows should also be free of obstructions
that would inhibit the driver’s ability to see out of the vehicle when driving. Door windows should be operational, in particular the driver’s door.
Accessories: Windshield wipers should be checked to determine if they are functional. The blades themselves should be in good condition, free of loose
or missing blade surface.
Approved warning/courtesy lights should be checked to determine if they are properly installed and operational. The vehicle operator should have the
proper permits and documentation for the warning/courtesy lights.
Repairs Needed: This section should be completed for any item that is suspect or in need of replacement or repair. The section should be torn off and
given to the vehicle owner/operator to take to the appropriate qualified party for inspection, replacement, or repair. Upon successful completion this section,
along with a work order/repair bill, should be returned to the organization as proof that the hazardous condition has been eliminated. Discretion should be
used by the organization as to whether an observe
d condition would warrant prohibiting the vehicle’s use in conjunction with the emergency service
organization until the repair and/or replacement is made.
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