2025 Brake Safety Week Data Form Country(Required) Canada Mexico United States of America Province or Territory(Required)Select your province/territoryAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonState or Territory(Required)Select your state/territoryAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingBadge/Inspector Number(Required)What level of CVSA inspection was conducted?(Required) Level I Level II Level IV Level V What level of CVSA inspection was conducted?(Required) Level I Level II Level IV Level V Performance-based brake tester (PBBT) Only Did you use a performance-based brake tester (PBBT) to conduct this inspection?(Required) Yes No Did the vehicle pass or fail (OOS) the overall 43.5% braking efficiency test?(Required) Pass Fail Did any of the wheel ends fail the 43.5% braking efficiency test?(Required) Yes No How many wheel ends failed the 43.5% braking efficiency test?(Required)Select a number12345678910Did you check at least one brake?(Required) Yes No What type of vehicle (power unit) was inspected?(Required) Truck Tractor/Truck-Trailer Combination Bus/Motorcoach Other What type of braking system is this power unit equipped with?(Required) Air – Disc Air – S-Cam Hydraulic What type of brakes are on the towed units?(Required) Air – Disc Air – S-Cam Hydraulic Electric Which vehicles had dust shields on the brakes?(Required) Power Unit Towed Unit(s) None Did you find any drum or rotor violations?(Required) Yes No What were the violations? Choose any that apply.(Required) Broken rotor(s) Rusted rotor(s) Metal-to-metal rotor(s) Broken drum(s) Was the vehicle or combination declared out of service for the brake system?(Required) Yes No Why was the vehicle or combination out of service?(Required) 20% Service Brake Violations Defective Linings/Pads on the Steering Axle Other Steering Axle Brake Violations Brake Hose/Tubing Violations Drum/Rotor Violations Air Loss Rate Test Other Brake Violations Was the vehicle or combination declared out of service for the brake system?(Required) Yes No Why was the vehicle or combination out of service?(Required) Failed 43.5% PBBT 20% Service Brake Violations Defective Linings/Pads on the Steering Axle Other Steering Axle Brake Violations Brake Hose/Tubing Violations Drum/Rotor Violations Air Loss Rate Test Other Brake Violations Found an interesting violation you'd like to share with us? Upload the pic.Max. file size: 256 MB.
