Inventory & Inspection Report

1
Inspector Name* This field is required.
Luis Giler
Please Select
Luis Giler
Other
2
Quarter* This field is required.
Please Select
Please Select
Q1
Q2
Q3
Q4
3
Date of Inspection* This field is required.
Month
Day
Year
4
Name of Driver* This field is required.
Please Select
Please Select
Javier
Jose
JR
Layni
Luis G.
Luis P.
Pedro
Ron
Shirley
5
Van ID* This field is required.
Please Select
Please Select
01
02
03
19
20
21
22
23
24
25
6
Mileage
7
Uniform Shirt (Fit, Condition):* This field is required.
Good
Other
8
Pants (Fit, Condition):* This field is required.
Good
Other
9
Shoes (Color, Safety/Style, Condition):* This field is required.
Good
Other
10
Hat (Optional):* This field is required.
Good
Not Worn
Needs
11
Van Cleanliness/Organization:* This field is required.Is the interior free of trash and debris? Is it presentable to patients, escorts and/or their families?
Good
Other
12
Van Exterior Wrap/Body:* This field is required.Is there any noticeable body or wrap damage that looks bad for the company image?
Good
Other
13
Hubcaps* This field is required.What is the condition of the hubcaps, are any in need of replacement or missing?
Good
Damaged/Needs Replaced
Missing
14
How many hubcaps are needed?
1
Please Select
1
2
3
4
15
Van Mechanical Issues* This field is required.
Yes, issue was already reported.
Yes, but not reported.
No issues.
16
Stretcher (Function/Condition):* This field is required.Does the stretcher need any repairs, or are any parts soon to need replacing?
Good
Not Applicable
Other
17
Stretcher Batteries/Charger:* This field is required.Each transit van should have 2 functioning batteries and a charger. Select all that apply.
All good. Has 2 functioning batteries and a charger
Needs battery replaced/repaired
Needs charger replaced
18
Wheelchair (Function/Condition):* This field is required.Please inspect condition of wheelchair and leg attachments. Is the wheelchair rusted or have broken parts? Is the cushion dirty and/or torn? Does the overall appearance represent the positive Shuttleliner image?
Good
Other
19
This Van is Equipped with a Bariatric WC:* This field is required.
Yes
No
20
Oxygen Tanks:* This field is required.Select all that apply.
Secured Properly in Transit
Sufficient O2 Level
Other
21
Equipment & Supplies
Good
Needs
NA
Slideboard
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Oxygen Tank Sleeve
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Transfer Sheets
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Chuck Pads
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Gloves holder/dispenser
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Cell Phone Holder
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Hand Sanitizer
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Disinfectant Wipes
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Marketing Items
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Company Credit Card
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Slideboard
Oxygen Tank Sleeve
Transfer Sheets
Chuck Pads
Gloves holder/dispenser
Cell Phone Holder
Hand Sanitizer
Disinfectant Wipes
Marketing Items
Company Credit Card
Good
Row 0, Column 0
Needs
Row 0, Column 1
NA
Row 0, Column 2
Good
Row 1, Column 0
Needs
Row 1, Column 1
NA
Row 1, Column 2
Good
Row 2, Column 0
Needs
Row 2, Column 1
NA
Row 2, Column 2
Good
Row 3, Column 0
Needs
Row 3, Column 1
NA
Row 3, Column 2
Good
Row 4, Column 0
Needs
Row 4, Column 1
NA
Row 4, Column 2
Good
Row 5, Column 0
Needs
Row 5, Column 1
NA
Row 5, Column 2
Good
Row 6, Column 0
Needs
Row 6, Column 1
NA
Row 6, Column 2
Good
Row 7, Column 0
Needs
Row 7, Column 1
NA
Row 7, Column 2
Good
Row 8, Column 0
Needs
Row 8, Column 1
NA
Row 8, Column 2
Good
Row 9, Column 0
Needs
Row 9, Column 1
NA
Row 9, Column 2
1 of 10
22
Inspector's Notes & Comments:Provide additional comments, concerns, or suggestions based on this inspection.
23
Inspector's Signature
24
Driver's Notes & CommentsIf the driver has any notes, comments, suggestions, and/or concerns, please provide them here. The driver can type notes, sign then submit the form.
Huge
Large
Normal
Small
Ok
Ok
25
Driver's SignatureSigning only acknowledges that the inspection took place in your presence; it does not imply agreement with the findings.
Should be Empty: