GISONT Daily Pre-Trip Inspection Form

• Location

  Lawton II

  Chickasha

  Duncan

  Wichita Falls

  Other

Vehicle Used:

• 1998 FORD Club Van 12 Passengers VIN 1FBSS31L1HHB56866

• 1998 MITSUBISHI Fuso Box Truck VIN JW6CCJ1G8WL00535

• 2004 CHEVROLET Venture 6 Passengers VIN 1GBDV13136D2243366

• 2006 CHEVROLET Uplander 4PCV Passenger VIN 1GBDV13L56D224366

• 2011 DODGE Grand Caravan 4PCV Passenger VIN 2D4RN4DG7BR770036

• 2013 GMC Savannah 15 Passenger VIN 1GJZ71FG2D1112448

• Conducted on

  Date

• Prepared by

UNDER HOOD

• Oil

  OK

  NEEDS ATTENTION

• Windshield Washer Fluid

  OK

  NEEDS ATTENTION

• Battery

  OK

  NEEDS ATTENTION

• Hoses/Belts

  OK

  NEEDS ATTENTION

• Coolent Leaks

  OK

  NEEDS ATTENTION

• Radiator Fluid

  OK

  NEEDS ATTENTION

• COMMENTS

SAFETY EQUIPMENT

• First Aid Kit

  OK

  NEEDS ATTENTION

• Bloodborne Kit

  OK

  NEEDS ATTENTION

• Flares/Triangles

  OK

  NEEDS ATTENTION

• Back Up Alarm

  OK

  NEEDS ATTENTION

• Seat Belt Cutter

  OK

  NEEDS ATTENTION

• Rear Door Buzzer

  OK

  NEEDS ATTENTION

• Accident Kits

  OK

  NEEDS ATTENTION

• Fire Extinguisher

  OK

  NEEDS ATTENTION

• COMMENTS

WHEELCHAIR LIFT & SECUREMENT

• Lift Mechanism

  OK

  NEEDS ATTENTION

  N/A

• Lift Belts

  OK

  NEEDS ATTENTION

  N/A

• Safety Plate

  OK

  NEEDS ATTENTION

  N/A

• Manual Pump Arm

  OK

  NEEDS ATTENTION

  N/A

• Shoulder Lap Belts

  OK

  NEEDS ATTENTION

  N/A

• Floor Securement

  OK

  NEEDS ATTENTION

  N/A

• Belts

  OK

  NEEDS ATTENTION

  N/A

• COMMENTS

EXTERIOR

• Mirrors

  OK

  NEEDS ATTENTION

• Tires

  OK

  NEEDS ATTENTION

• Head Lights

  OK

  NEEDS ATTENTION

• Marker Lights

  OK

  NEEDS ATTENTION

• Tail/Brake Lights

  OK

  NEEDS ATTENTION

• Turn Signals

  OK

  NEEDS ATTENTION

• Windshield Wipers

  OK

  NEEDS ATTENTION

• Body Damage

  OK

  NEEDS ATTENTION

  N/A

• Take a Picture of the Damage

  Media

• Cleanliness

  OK

  NEEDS ATTENTION

• Doors

  OK

  NEEDS ATTENTION

• COMMENTS

INTERIOR

• Steering

  OK

  NEEDS ATTENTION

• Transmission

  OK

  NEEDS ATTENTION

• Horn

  OK

  NEEDS ATTENTION

• Mirrors

  OK

  NEEDS ATTENTION

• Gauges

  OK

  NEEDS ATTENTION

• Heater/AC

  OK

  NEEDS ATTENTION

• Radio

  OK

  NEEDS ATTENTION

• Cleanliness

  OK

  NEEDS ATTENTION

• Vehicle Brakes & Parking Brakes

  OK

  NEEDS ATTENTION

• Step Well & Dome Lights

  OK

  NEEDS ATTENTION

• Emergency Exit

  OK

  NEEDS ATTENTION

• COMMENTS

PASSENGER INFORMATION

• Number of Ambulatory (Passengers Able to Walk)

• Number of Non-Ambulatory (Passengers Not Able to Walk)

• Total Number of Trips Made To work site and back counts as 2 trips. If you have 10 passengers and they traveled to the work site and back in the van then the "Total Number of Trips Made" is 20

• COMMENTS

• Passenger Names: