Field Sup Vehicle Inspection Form TEAMBUILD - HST Vehicle Inspection Safety ReportProgram/Inspection Site: Check All That Apply DDS DMH DPH/EIP DMA/MH MCB MRC City/Town: Transportation Provider:NURSECARE TRANSPORTATIONBLANKTime of Inspection:Date of Inspection: MM slash DD slash YYYY Nursecare Inspector Name: SignatureInspector Arrival Time: Inspector Departure Time: 1. Vehicle on time (program/home/site) Yes No 2. Vehicle operated in safe manner Yes No 3. Exterior clean & free of damage Yes No 4. Company name/lettering clearly visible (pass. side & rearm=, w/min of 2" high letters) Yes No 5. Windows, glas, lights and wipers intact Yes No 6. Vehicle seating capacity not exceeded Yes No 7. Valid (passed) MA vehicle inspection sticker Yes No 8. Safe Tires (for all seasons) Yes No 9. Valid Mass. Drivers License in hand or contiguous state license: MA NH RI CT NY VT 10. Valid MA registration on board Yes No 11. Vehicle no older than 5 yrs (7 for w/c) Mfg. Date (program-based only) Yes No N/A 12. Driver First Aid & CPR Certs(DPH only) Yes No N/A 14. First aid kit (complete) Yes No 13. Working two-way radio/cellular phone Yes No 15. Seat belt cutter required. Extensions when needed Yes No 16. Fire extinguisher (fully charged) and other safety equipment (chock blocks, triangles etc.) Yes No 17. All equipment properly secured Yes No 18. Interior clean & free of damage Yes No 19. AC and heater cool/heat entire vehicle (seasonal) Yes No 20. Vehicle is smoke free Yes No 21. All passenger "fact sheet" data available Yes No 22. Daily vehicle inspection documented Yes No 23. All scheduled consumers transported Yes No 24. Only authorized riders in vehicle Yes No 25. Driver & monitor assist consumers when entering and exiting the vehicle Yes No 26. Drive & monitor assist in securing & releasing children and car seats Yes No N/A 27. Children are properly secured in car seats Yes No N/A 28. Driver ensures all occupants are properly secured with seatbelts prior to any movement of the vehicle Yes No 29. No consumers in side or rear facing seats (all consumers in front facing seats Yes No 30. All children are seated in the rear passenger seats of vehicles equipped with passenger side air bags Yes No N/A 31. Wheelchair/medical equipment must be properly secured (WC must face forward) Yes No N/A 32. Driver/Monitor is in the vehicle (when required) Yes No N/A 33. Driver& monitor wear a photo ID (program-based) Yes No N/A 34. Driver & monitor have a positive attitude and appearance and can communicate effectively Yes No 35. Monitor sits in one of the rear seats of the vehicle with the consumers Yes No N/A 36. Driver & monitor meet age requirements (minimum 19 years old), check ID Yes No 37. Other (explain under "Remarks'") Yes No Driver Name: Vehicle Reg # Vehicle YearMonitor Name: Vehicle Type: WC Ambulatory Seating CapacityRemarks (explain briefly any negative report, please be specific & list the name of any consumer involved):Program Manager Signature:Review Date MM slash DD slash YYYY Follow-up completion date: MM slash DD slash YYYY TEAMBUILD - HST Vehicle Inspection Safety ReportProgram/Inspection Site: Check All That Apply DDS DMH DPH/EIP DMA/MH MCB MRC City/Town: Transportation Provider:NURSECARE TRANSPORTATIONBLANKTime of Inspection:Date of Inspection: MM slash DD slash YYYY Nursecare Inspector Name: SignatureInspector Arrival Time: Inspector Departure Time: 1. Vehicle on time (program/home/site) Yes No 2. Vehicle operated in safe manner Yes No 3. Exterior clean & free of damage Yes No 4. Company name/lettering clearly visible (pass. side & rearm=, w/min of 2" high letters) Yes No 5. Windows, glas, lights and wipers intact Yes No 6. Vehicle seating capacity not exceeded Yes No 7. Valid (passed) MA vehicle inspection sticker Yes No 8. Safe Tires (for all seasons) Yes No 9. Valid Mass. Drivers License in hand or contiguous state license: MA NH RI CT NY VT 10. Valid MA registration on board Yes No 11. Vehicle no older than 5 yrs (7 for w/c) Mfg. Date (program-based only) Yes No N/A 12. Driver First Aid & CPR Certs(DPH only) Yes No N/A 14. First aid kit (complete) Yes No 13. Working two-way radio/cellular phone Yes No 15. Seat belt cutter required. Extensions when needed Yes No 16. Fire extinguisher (fully charged) and other safety equipment (chock blocks, triangles etc.) Yes No 17. All equipment properly secured Yes No 18. Interior clean & free of damage Yes No 19. AC and heater cool/heat entire vehicle (seasonal) Yes No 20. Vehicle is smoke free Yes No 21. All passenger "fact sheet" data available Yes No 22. Daily vehicle inspection documented Yes No 23. All scheduled consumers transported Yes No 24. Only authorized riders in vehicle Yes No 25. Driver & monitor assist consumers when entering and exiting the vehicle Yes No 26. Drive & monitor assist in securing & releasing children and car seats Yes No N/A 27. Children are properly secured in car seats Yes No N/A 28. Driver ensures all occupants are properly secured with seatbelts prior to any movement of the vehicle Yes No 29. No consumers in side or rear facing seats (all consumers in front facing seats Yes No 30. All children are seated in the rear passenger seats of vehicles equipped with passenger side air bags Yes No N/A 31. Wheelchair/medical equipment must be properly secured (WC must face forward) Yes No N/A 32. Driver/Monitor is in the vehicle (when required) Yes No N/A 33. Driver& monitor wear a photo ID (program-based) Yes No N/A 34. Driver & monitor have a positive attitude and appearance and can communicate effectively Yes No 35. Monitor sits in one of the rear seats of the vehicle with the consumers Yes No N/A 36. Driver & monitor meet age requirements (minimum 19 years old), check ID Yes No 37. Other (explain under "Remarks'") Yes No Driver Name: Vehicle Reg # Vehicle YearMonitor Name: Vehicle Type: WC Ambulatory Seating CapacityRemarks (explain briefly any negative report, please be specific & list the name of any consumer involved):Program Manager Signature:Review Date MM slash DD slash YYYY Follow-up completion date: MM slash DD slash YYYY
