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Vehicle Inspection Report

This document is a vehicle safety inspection form required by Wisconsin health and family services regulations. It provides instructions for licensees to have their vehicle inspected by a garage, dealership, or auto repair shop. The inspector is to complete the form, checking for any issues with the brakes, suspension, steering, exhaust, safety features, wipers/blades, and tires. Any items that fail or need repair/replacement should be noted. The completed form must then be returned to the licensing specialist.

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Virna Lassiter
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Download as PDF, TXT or read online on Scribd
2K views

Vehicle Inspection Report

This document is a vehicle safety inspection form required by Wisconsin health and family services regulations. It provides instructions for licensees to have their vehicle inspected by a garage, dealership, or auto repair shop. The inspector is to complete the form, checking for any issues with the brakes, suspension, steering, exhaust, safety features, wipers/blades, and tires. Any items that fail or need repair/replacement should be noted. The completed form must then be returned to the licensing specialist.

Uploaded by

Virna Lassiter
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN

Division of Children and Family Services


CFS-52 (Rev. 08/2000)

VEHICLE SAFETY INSPECTION


Use of form: Completion of this form is required by HFS 45.06(8)(d)2, HFS 46.08 (7)(b) and HFS 52.47 (6)(a)1. Failure to complete
may result in a licensing enforcement action. Personally identifiable information on this form will be used only to verify the vehicle
inspection.

Instructions: This form is to be provided to a garage, dealership or auto repair shop, to be completed by them after inspecting the
vehicle. The licensee shall return the completed form to the Licensing Specialist.

Name - Facility

Type
Family Day Care Group Day Care Day Camp RCC / Children and Youth
Vehicle - Year Make Model Color Odometer Reading License Plate Number

Name - Inspecting Company or Agency Name - Inspector Telephone Number

Address City State Zip Code

VEHICLE INSPECTION CHECKLIST


Repair/ Repair/
Item Pass Item Pass
Replace Replace
BRAKES SAFETY FEATURES
1. Failure indicator light 17. Turn signals operational
2. System integrity 18. Head lights
3. Pedal reserve 19. Tail lights
4. Disc/drum condition 20. Brake lights
5. Hoses and assembly 21. Horn
SUSPENSION 22. Windows/Windshield (cracks/chips)
6. Shock absorbers/struts 23. Front seat safety belts condition
7. Springs 24. Back seat safety belts condition
8. Shackles 25. Door locks operational
9. Modifications WIPERS/WIPER BLADES
STEERING 26. Wipers operational
10. Lash 27. Blades contact
11. Free turning 28. Blades condition
12. Linkage play TIRES - FRONT Lft Rt Lft Rt
13. Power system 29. Tread depth
EXHAUST SYSTEM 30. Matching
14. Leaks 31. Condition
15. Legal muffler TIRES - REAR Lft Rt Lft Rt
16. Tailpipe 32. Tread depth
33. Matching
34. Condition
Brief Comments - Refer to Item Number

SIGNATURE - Inspector Date - Inspection

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