Weekly Maintenance Inspection
Please complete by close of business each Friday.
Employee/Volunteer Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Mileage
*
Agency Vehicle
*
Please Select
WC-05
WC-06
WC-07
WC-08
VTC-5
NYS Inspection Due
*
-
Month
-
Day
Year
Date
Registration Due
*
-
Month
-
Day
Year
Date
Checklist
*
Working
Needs Repair
Missing
All interior lights
All exterior lights
Tire Pressure
Wiper Blades
Heat/AC working
Fire Extinguisher
Ramp
Doors
Wiper Blades
Safety Triangles
Battery
Brakes
Seat belts
PPE
Wheelchair
Picture of Interior
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of
Picture of exterior
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of
Overall Condition of Vehicle
*
1
2
3
4
5
Additional Notes
Submit
Should be Empty: