SMS Auto Safety Checklist 2017

• Document No.

• Employee Name

• Client / Site

• Conducted on

  Date

• Manager Name

Employee Info

• Date of Inspection

  Date

• Manager Name

• Employee Name

• Insurance Carrier, policy number, and expiration date. A clear picture of card is acceptable too.

• Insurance card

  Media

• Vehicle Make and Model

• Primary Vehicle

• Secondary Vehicle

Vehicle Inspection

• Any marked items for repair will be assigned a deadline for completion. Failure to complete the noted repairs by the deadline, will result in suspension from your driving duties until they are corrected on or before your final deadline to repair your vehicle. Any further failures will result in a longer suspension from driving duties or termination of your employment.

• Is there a place for a Silver Mine Subs sign

  Yes

  No

  N/A

• Both front and rear turn signals are working

  Yes

  No

  N/A

• Horn is working

  Yes

  No

  N/A

• Rear view mirror is in good repair

  Yes

  No

  N/A

• Both side view mirrors are in good repair

  Yes

  No

  N/A

• Left

  Yes

  No

  N/A

• Right

  Yes

  No

  N/A

• Vehicle registration is up to date. Newest tags are on the plates

  Yes

  No

  N/A

• Back up lights are in good repair and working

  Yes

  No

  N/A

• Windshield is in good repair. Must be replaced or repaired, if there is any damage.

  Yes

  No

  N/A

• Brake lights working and in good repair

  Yes

  No

  N/A

• Cigarette lighter/Power port is working

  Yes

  No

  N/A

• Are there any offensive bumper stickers or other offensive markings?

  Yes

  No

  N/A

• Do you have a secondary delivery vehicle

  Yes

  No

  N/A

• Do you have maps or GPS

  Yes

  No

  N/A

• Headlights are working and in good repair

  Yes

  No

  N/A

• Left

  Yes

  No

  N/A

• Right

  Yes

  No

  N/A

• Are tires in good repair. Photograph and Note any that need attention. Use tire tread depth gauge (keep it stored in office key box, when not in use). Tires with tread depths at or below 4/32" will need to be replaced within two weeks from the date of this inspection, no exceptions. Spare tire is in car and in good repair?

  Yes

  No

  N/A

• Right Front

  Safe

  At Risk

  N/A

• Left Front

  Safe

  At Risk

  N/A

• Right Rear

  Safe

  At Risk

  N/A

• Left Rear

  Safe

  At Risk

  N/A

• Spare

  Yes

  No

  N/A

• Miscellaneous notes for any other issues not noted in the inspection

Acknowledgement of Vehicle Inspection

• By signing you acknowledge that you will repair any marked items on or before the date your supervisor has given you to correct them.

• Employee Signature

  Sign

• Manager Signature

  Sign