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
000001 2005, Mercedes-Benz, Actros
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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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