VEHICLE SAFETY INSPECTION CHECK LIST DATE
NAME OF OWNER (RANK, LAST, FIRST, MI) DRIVERS LIC. #/STATE EXPIRATION
DATE
SOCIAL SECURITY LAST 4 ORGANIZATION STATE REGISTRATION EXPIRATION
DATE
YR/MAKE/MODEL OF VEHICLE LICENSE PLATE # / ST COLOR
INSURANCE COMPANY NAME INSURANCE POLICY # EXPIRATION
DATE
GO NO-GO
ITEM DEFECTIVE ITEM(S) INITIAL
LIGHTS: Do they work? Are they cracked?
(High & low HEAD / TAIL / EMERGENCY / BACK UP /
TURNSIGNALS / PARKING / BRAKE / LICENSE PLATE)
HORN:
Functional?
BRAKES: Will the emergency brake hold?
WINDSHIELD WIPERS: Both wipers present and
in good condition? Rear if applicable.
WINDSHIELD: Free from cracks that impair vision?
TIRES (Include Spare): At least 1mm of tread over
the entire traction surface? Penny: If you can see the top of
Lincoln’s head, not enough TREAD! Inflation?
EXHAUST SYSTEM:
Free of leaks? Excessive noise or smoke coming from exhaust?
REAR VIEW MIRROR:
Serviceable? Side mirrors if applicable?
DOORS AND GLASS:
Open and close freely? Cracked glass? Tinted no more than
legal limit? Check at craft shop.
FUEL TANK:
Free from leaks? Gas cap missing?
SEAT BELTS:
One for each seating position, serviceable?
ALL FLUIDS: Fluids filled to correct level?
(OIL / TRANSMISSION / STEERING / CLUTCH /
BRAKES /COOLANT/ WINDSHIELD WASHER)
BABY/CHILD SEAT (as applicable):
SECURED / INSTALLED PROPERLY
C 1/78 FORM 1257-R-E (PM) 16 MAR 10 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE.
SAFETY PLEDGE
I, _ ________ pledge that while I am on leave, pass, permissive TDY, or in an off duty status, I will remain safety conscious
at all times.
___I will absolutely take no unnecessary risk that may endanger my life, the lives of others around me or prevent my safe return.
___I will observe all state and post traffic laws and be alert for warning signs.
___I will wear my seatbelt at all times while driving or riding in a vehicle.
___I will wear a helmet at all times while operating a motorcycle and wear a reflective vest to make myself highly visible to other
traffic.
___I will get a good night’s rest before beginning any long trip.
___I will take appropriate rest stops when driving for long distances and drive at safe speeds determined by weather and road
conditions.
___I will not consume alcoholic beverages while driving, boating, skiing, swimming, or whenever my reflexes and ability are
needed to prevent an accident. I will not use illegal drugs at any time.
___I will not operate a motor vehicle or other equipment while using prescription drugs that make you drowsy and I will not use
them for unsafe activities.
___As a dedicated soldier, I do pledge that the number one priority while on leave or pass will be to think safety in all my activities
and return to Fort Sill safely, remembering that “a soldier’s life cannot be replaced.”
___If I become delayed or have a problem returning on time, I will inform my Chain of Command.
I do /do not own a privately owned weapon (firearm). While on leave, I will store it at the (initial your choice):
- My on/off post quarters (may not be stored in the barracks) - _________
- Unit Arms Room - _______
I will notify my chain of command if I plan to be gone from my quarters overnight. If I leave the area overnight,
I will maintain a contact address and telephone number during the entire period of my authorized absence. If my
contact address/telephone number changes at any time during my absence, I will notify the unit chain of command
immediately. If I am recalled from my absence, I understand that I must return to duty within 24 hours by the most
expeditious and safe means possible unless otherwise directed by the Commander or First Sergeant. I understand that
my failure to return to the unit within the specified time without reason may subject myself to disciplinary action under
the UCMJ.
REMARKS:
SIGNATURE (Owner) SIGNATURE (INSPECTOR, SFC or above) Print DATE
and Sign
C 1/78 FORM 1257-R-E (PM) 16 MAR 10 PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE.
