AMBULANCE INSPECTION VEHICLE AND REASON FOR INSPECTIONVEHICLE NUMBERA2A4REASONNew Vehicle/ServiceVehicle InspectionLEVEL OF SERVICE WHEN INSPECTEDBASICINTERMEDIATEPARAMEDICINSPECTOR NAME DATE OF INSPECTION MM slash DD slash YYYY VEHICLE SAFETY INSPECTION - LIGHTINGHigh and Low Beam Headlights operational YES NO N/A Clearance, Marker lights, and Reflectors operational YES NO N/A Dashboard lights and interior lights YES NO N/A High beam indicator light (on dashboard) YES NO N/A Left and right tail lights operational YES NO N/A Left and right front turn signals operational YES NO N/A Left and right rear turn signals operational YES NO N/A Left and right brake lights operational YES NO N/A License plate light operational YES NO N/A Back-up lights operational YES NO N/A Emergency Lighting Operational YES NO N/A VEHICLE SAFETY INSPECTION - TIRES/WHEEL/BRAKESTread depth 1/16 in minimum on all tires YES NO N/A Tread and sidewall free of major deformities YES NO N/A Rims/wheels free of significant damage YES NO N/A Brake Pedal Travel 2/3 for non-assisted brakes YES NO N/A Brake Pedal Travel 4/5 for power brakes YES NO N/A Emergency Lighting Operational YES NO N/A VEHICLE SAFETY INSPECTION - STEERING/SUSPENSIONSteering shaft secure, no more than 1/4 turn play YES NO N/A Power steering operational YES NO N/A Tires have full range of motion without rubbing YES NO N/A Shocks/Springs mounted and intact YES NO N/A Air ride suspension properly inflates/deflates YES NO N/A VEHICLE SAFETY INSPECTION - WINDSHIELD/WINDOWS/MIRRORSWindshield without breach, unobstrcted YES NO N/A Windshield wipers and washers YES NO N/A Windows without breach and consistent YES NO N/A Rear view mirrors without breach and IAW YES NO N/A VEHICLE SAFETY INSPECTION - WARNING DEVICESAudible back up alarms operational YES NO N/A Horn operational and audible YES NO N/A Siren operable and audible YES NO N/A MISCELLANEOUSDriver and passenger safety belts operational YES NO N/A Driver and passenger safety belts free of visible damage YES NO N/A Seats securely fastened to floor YES NO N/A Floor intact and free of holes YES NO N/A Interior free of protrusions, trash and debris YES NO N/A Structural integrity without breach (body and frame) YES NO N/A Heater, defroster and A/Cinstalled and operational YES NO N/A Exhaust system secured and without breach YES NO N/A Fuel tank free of leaks and securely mounted YES NO N/A License plates front and rear YES NO N/A Two-way communications with dispatch YES NO N/A Service name/logo permanently on vehicle YES NO N/A Conformanceplacard, sticker , or affidavit YES NO N/A NOTES
