Vacation, Repair and Short Term Disablilty Survey

Team,

This survey is specifically for those that did not complete the previous month(s) survey due to the following reasons:

Vacation- You were out on PTO during the entire time the survey was open.

Illness- You had been sick for the entire time that the survery was open

Your vehicle was being repaired during the entire time the survey was open.

You have been out on disability for an extended period of time.

Please fill out as much of the information as you can.

Marisue

Select this box to acknowledge that you have read this memo

Employee Information:

* Your Name (No division information here)

* Enter your Division

Please state the reason you are filling out the exception survey instead of the standard monthly survey.

Vehicle Information

* Odometer Reading "at time of survey" (Please round off, do not include 10ths of miles)

Please enter the last six digits of your vehicle VIN.

License Plate Number

* The state vehicle is registered in.

Registration Expiration Date (Only if this has changed since last months survey)

Vehicle Maintenance Information

* Date of Last Service

Month	Day	Year

Turn Signals, front and rear, left and right sides

Running Lights, front and rear

Brake Lights, left and right

Both Side View Mirrors

Rear View Mirror (if installed)

New (replaced within the last 5,000 miles)

Good (based on information received at time of last service)

Need Replacing (3/32nd of an inch or less tread left)"Please discuss getting these replaced with your manager as soon as possible"

Windshield Washer Fluid

Power Steering Fluid

Accident Information

It is mandatory to report "all" accidents or incidents"
If so,have you reported this to Fleet Management, Human Resources, and completed the Vehicle Accident Report Form posted on SharePoint?

Please list any damage to this vehicle. This would include any dents or scratches that were not reported in a prior survey. (A dent is defined as anything larger than a Quarter. A scratch is defined as anything longer than 5 inches). You may be asked to submit photos of any damages.

Miscellaneous Questions

* Does your vehicle have secure and lockable area for EFT devices?

* By Entering you name, you acknowledge that you have conducted this inspection and verify its accuracy.