Pendle

Attach Photo(s):

Notes (Not Public):

Serial Number:

Service

Please select item type:

Reason for Examination

Details of Truck

Make:

Model:

Serial Number:

Fleet No:

Date of Manufacture:

Attachments:

Hours:

Description:

Mast Configuration:

Safe Working Load:

SWL with Attachments:

Chain Cert. Seen?:

Yes No

Defects

A � Defects which could cause a danger to persons. Description of repair, renewal or alteration required and the timescale within which those defects shall be rectified.

B � Identification of any other parts that require rectification (no timescale required).

C- Observations, recommendations and action required if any.

Defects

Measurements & Other Examinations

Chain Elongation (Inner, 3%)

Chain Elongation (Outer, 3%)

Chain Leaf Wear (Inner, 5%)

Chain Leaf Wear (Outer, 5%)

Fork Blade Difference (3%)

Fork Heel Wear (10%)

Have any other tests been carried out?

Yes No

Outcome

Outcome of Examination:

Reason for Visit:

Fault Details:

Outcome:

Vehicle Off Road
OK To Use

Parts Used:

Qty

Description

Part No

Action Taken:

If other, give details:

Parts or 3rd Party Required:

Qty

Description

Part No

Hour Meter Reading:

Damaged:

Yes No

Customer Order Number:

Travel Time:

Appointment Time Taken:

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Customer Forename*:

Customer Surname*:

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Product Handover - Chair / Bed

1. I have received the owner's manual and its contents have been explained to my satisfaction

Yes No N/A

2. The chair/bed has been placed in a suitable position in my home for me to use

Yes No N/A

3. I have been shown how to attach the power supply to the chair/bed and plug it in to the mains

Yes No N/A

4. I have been shown how to operate the chair/bed using the hand control

Yes No N/A

5. The battery backup system has been fully explained to me

Yes No N/A

6. I have been shown how to raise the chair/bed to the stand position

Yes No N/A

7. I have been shown how to recline the chair/bed to the fully reclined position

Yes No N/A

8. I have been shown how to operate the rise & recline chair/bed safely. I understand that I can refer to the owner's manual for further information on safety, operation and maintenance.

Yes No N/A

9. No property, fixtures or fittings belonging to me have been damaged in any way

Yes No N/A

10. I acknowledge that the rise & recline chair/bed has been received in good condition and in good working order.

Yes No N/A

Product Handover - Scooter

1. I have received the owner's manual and its contents have been explained to my satisfaction

Yes No N/A

2. The battery charging procedure has been explained, I understand that I must charge the battery for 8-12 hours after each use, the key must be removed, and if applicable I will leave the battery on charge for 24 hours before initial use.

Yes No N/A

3. I have been shown how to operative the key ignition, lights, hazard lights, indicators and horn (where applicable)

Yes No N/A

4. I have been shown how to use forward and reverse throttle controls

Yes No N/A

5. I have been shown how to adjust the speed and that 8mph EPV must be set at 4mph max for use on pavements (where applicable)

Yes No N/A

6. I have been shown how to use forward and reverse throttle controls

Yes No N/A

7. I have been shown how to brake safely using the automatic braking system (including handbrake on 8mph models if fitted)

Yes No N/A

8. I have been shown how to dismantle the mobility aid (where applicable)

Yes No N/A

9. I have been shown how to use the free wheel mechanism

Yes No N/A

10. I have had the seat adjusted so that I am in a comfortable position

Yes No N/A

11. All of the above have been demonstrated, and tried so that I am comfortable of use

Yes No N/A

12. I agree that I have been shown how to operate the mobility scooter safely. I understand that I can refer to the owner's manual for further information on safety, operation and maintenance.

Yes No N/A

13. I am able to move the mobility scooter from my property storage area to my property exit

Yes No N/A

14. I have been taken for a test drive which lasted 5 minutes

Yes No N/A

15. No property or fixtures or fittings belonging to me have been damaged in any way

Yes No N/A

16. I acknowledge that the mobility scooter has been received in good condition and in good working order.

Yes No N/A

Service Certificate

1. Battery Capacity Test

OK Not OK N/A

2. Battery Charger Tested

OK Not OK N/A

3. Motor Brushes Checked

OK Not OK N/A

4. Motor Drawn and Checked

OK Not OK N/A

5. Motor Brake Checked and Cleaned

OK Not OK N/A

6. Check Electric leads for chaffing and Wear

OK Not OK N/A

7. Console: All Functions Working Correctly

OK Not OK N/A

8. Check Tightness of Nuts and Bolts

OK Not OK N/A

9. Wheel Bearings Checked

OK Not OK N/A

10. Tyres/ Rims: No Visible Damage

OK Not OK N/A

11. Check and Lubricate Lubrication Points

OK Not OK N/A

12. Front Brake (where fitted) Operates Correctly

OK Not OK N/A

13. Seat: All Functions Working Correctly

OK Not OK N/A

14. Steering Column Set Correctly

OK Not OK N/A

15. Fully Cleaned and Valeted

OK Not OK N/A

16. Test Drive: All Functions Working

OK Not OK N/A

17. Test Drive: No Undue Vibration or Noise

OK Not OK N/A

Additional Information:

Action to be Taken:

Service / Repair Order

Work Carried Out:

Other Action to be Taken:

Glass / Mirrors / Bodywork
Front & Rear Sidelights and Foglights
Headlights Main and Dipped Beam
Brake Lights and Reversing Lights
Horn, Wipers and Washers
Numberplate Visibility and Rear Light
Wheel Damage

Front:
Rear:
Driver:
Passenger:

Engine Oil Level / Coolant
Water / Oil / Fluid Leaks
Washer Fluid / Brake Fluid

Seat Belts Operation
Handbrake Operation
Dashboard Warning Lights

Bodywork
Vehicle Washed & Cleaned