2005, Mercedes-Benz, Actros - 000001 - SafetyCulture

Heavy Vehicle Inspection

Driver Name: 000001 Conducted on 5/08/2015 11:24 am Vehicle Year, Make, Model. 2005, Mercedes-Benz, Actros VIN Number 1111111111 Submitted To: ABC Company Completed on 5/08/2015 11:30 am Score 39/39 - 100%

Disclaimer The assessors believe the information contained within this risk assessment report to be correct at the time of printing. The assessors do not accept responsibility for any consequences arising from the use of the information herein. The report is based on matters which were observed or came to the attention of the assessors during the day of the assessment and should not be relied upon as an exhaustive record of all possible risks or hazards that may exist or potential improvements that can be made. Information on the latest workers compensation and OHS / WHS laws can be found at the relevant State WorkCover / WorkSafe Authority. Confidentiality Statement In order to maintain the integrity and credibility of the risk assessment processes and to protect the parties involved, it is understood that the assessors will not divulge to unauthorized persons any information obtained during this risk assessment unless legally obligated to do so.

000001 2005, Mercedes-Benz, Actros

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Table of Contents HEAVY VEHICLE INSPECTION - 39/39 - 100% Disclaimer Confidentiality Statement AUDIT ADMINISTRATIVE SAFETY & PROJECT MANAGEMENT INTERIOR OF VEHICLE EXTERIOR & MECHANICAL CARGO & EQUIPMENT (LEAN) PLEASE PROVIDE PHOTOS IF EQUIPPED WITH A TRAILER Signature MEDIA

1 2 2 4 4 4 4 4 5 5 6 6 8

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Audit - 39/39 - 100% Question

Response

ADMINISTRATIVE

Details Score (2/2) 100%

Registration & insurance cards are current?

Yes

License plate and tags are current?

Yes

SAFETY & PROJECT MANAGEMENT

Score (7/7) 100%

Foreman's Manual is up to date with claims reporting forms?

Yes

Foreman's Manual is up to date with national account forms?

Yes

MSDS binder present & accounted for?

Yes

Health & Safety Manual in the truck?

Yes

First Aid kit is complete and items within the expiration date?

Yes

Fire extinguisher mounted with current inspection tag?

Yes

Sure off tester and water management tools on truck?

Yes

INTERIOR OF VEHICLE

Score (3/3) 100%

Interior clean of trash and dirt?

Yes

Instrument panel is indicating properly?

Yes

Windshield and mirrors clean and free from cracks?

Yes

Please provide a photo of the interior.

Appendix 1

EXTERIOR & MECHANICAL

000001 2005, Mercedes-Benz, Actros Score (39/39) 100%

Score (15/15) 100%

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Question Date of last service?

Response

Details

01 Jan 2015

Backup lights?

Safe

Belts & Hoses?

Safe

Brakes? (Pedal Pressure)

Safe

All Fluid Levels?

Safe

Oil Coolant Visible Fluid Leaks?

Safe

Emergency Flashers?

Safe

Headlights?

Safe

Tail Lights?

Safe

Turn Signals?

Safe

Horn?

Safe

Steering & Alignment?

Safe

Tyres & Pressure?

Safe

Windshield/Wiper Blades/Fluid?

Safe

CARGO & EQUIPMENT (LEAN)

Score (4/4) 100%

All equipment is secured & adequately stored?

Safe

Truck is organized & free of excessive material?

Safe

PLEASE PROVIDE PHOTOS Driver's Side

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Appendix 2

Passenger's Side

Appendix 3

Bed of truck

Appendix 4

IF EQUIPPED WITH A TRAILER

Score (8/8) 100%

Trailer has been checked for proper connection to the vehicle?

Safe

Brakes if equipped?

Yes

Cargo Secure?

Yes

Lights/Marker Lamps?

Yes

Springs Appear OK?

Yes

Straps/Tie Downs?

Yes

Trailer Tires & Pressure?

Yes

Trailer Platform Integrity?

Yes

Signature

000001 2005, Mercedes-Benz, Actros Score (39/39) 100%

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Question

Response Bob Smith

000001 2005, Mercedes-Benz, Actros Score (39/39) 100%

Details

5/08/2015 11:30 am

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Media

Appendix 1

Appendix 2

Appendix 3

Appendix 4

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