Company Vehicle Safety Checklist

Company Vehicle Safety Checklist
Vehicle # (N/A if no #)*
Last 5 Digits of VIN #*
License Plate #*
Mileage*
Safety Items Checklist
Is your vehicle equipped with fire extinguisher ?*

YesNo
Is your fire extinguisher strapped and easy to access?*

YesNo
Fire extinguisher inspection / service date?*

MonthDayYear
Date
Is your vehicle equipped with a first aid kit?*

YesNo
Do you need refills of any items of your first aid kit?*

YesNo
You Answer Yes to the above, What are the refill items needed?*
Is your vehicle equipped with useable safety googles ?*

YesNo
Is your vehicle equipped with useable safety glasses ?*

YesNo
General Appearance and Mechanical Notes
Has the vehicle been washed with in the last 15 days ?*

YesNo
Is the interior of the vehicle cleaned in the last 7 days?*

YesNo
Is there body damage to the vehicle?*

YesNo
Are the brake lights working properly?*

YesNo
Are the reverse lights working properly?*

YesNo
Is the vehicle horn working properly?*

YesNo
Are the vehicle breaks working and in good conditions?*

YesNo
Does your assigned company vehicle need an Oil Change?*

YesNo
Does your assigned company vehicle have an Oil life display ?*

YesNo
What is the Oil life % displayed ?*
Please note any issues with your assigned company vehicle in this section. If none please write "NONE". ?*
Company Vehicle Tire Condition
Left Front*

PoorFairGood
Right Front*

PoorFairGood
Left Rear*

PoorFairGood
Right Rear*

PoorFairGood
Documents
Is your Driver's License valid?*

YesNoN/A
Is the Registration current?*

YesNoN/A
Is the Insurance Card current?*

YesNoN/A
Driver Health
Do you feel safe driving your assigned company vehicle?*

YesNo
You answer NO to the above, what are your Safety Concerns about driving your assigned company vehicle?*
Do you currently have any medical conditions that impair your driving ?*

YesNo
You Answer Yes to the above, What are the Medical Conditions that impair your driving?*
I certify that the above information is correct and accurate as of the date on this form and that I have not experienced any work related injuries related to operating a company vehicle that have not been reported to my manager and/or human resources.
Driver Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Company Vehicle Safety Checklist

Safety Items Checklist

General Appearance and Mechanical Notes

Company Vehicle Tire Condition

Documents

Driver Health