DOD Inspection Data Submission Form Were you able to conduct the planned inspection?(Required) Yes No Date of planned inspection(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920State/Territory(Required)Select a State or TerritoryAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingName of DOD point of contact that was contacted or attempted to be contacted First Last Email address of DOD point of contact that was contacted or attempted to be contacted Phone number of DOD point of contact that was contacted or attempted to be contactedReason the inspection was not completed (select all that apply)(Required) Unable to contact unit point of contact by phone Unable to contact unit point of contact by email Denied access to military base or facility Vehicle to be inspected did not arrive at the designated time Vehicle to be inspected left prior to designated time Inspector diverted to priority call Other Please explain the reason the inspection was not completed(Required)Was the unit point of contact present?(Required) Yes No Date the inspection was conducted(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Inspection Start Time Hours : Minutes AM PM AM/PM Inspection End Time Hours : Minutes AM PM AM/PM In which state or territory was the inspection conducted?(Required)Select a State or TerritoryAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWhat level of inspection was completed?(Required) Level I – North American Standard Inspection Level II – Walk-Around Driver/Vehicle Inspection Level III – Driver/Credential/Administrative Inspection Level V – Vehicle-Only Inspection Bus/Vehicle make and year (from carrier equipment list)(Required)USDOT Number(Required)Vehicle Identification Number (VIN)(Required)Movement Request Number (MRN) (located on monthly spreadsheet)(Required)Were there any violations?(Required) Yes No Total number of violations(Required)Number of out-of-service DRIVER violations(Required)Number of out-of-service VEHICLE violations(Required)Briefly describe the violation(s).(Required)Was a CVSA decal issued?(Required) Yes No Movement Request Number (MRN) of attempted inspection (located on monthly spreadsheet)(Required)Attach supporting documents or photos Drop files here or Select files Max. file size: 512 MB. Additional comments/condition of bus/vehicle (restroom, cleanliness, etc.)Comments/Notes
