Vehicle Emissions Inspection Failure Report Form
Use this form to report a failed vehicle emissions inspection, document the failure details, and organize repair and reinspection follow-up.
Vehicle Information
Vehicle Year
*
Make
*
Model
*
Trim or Body Type
Fuel Type
*
Please Select
Gasoline
Diesel
Hybrid
Electric
Plug-in Hybrid
Flex Fuel
Other
License Plate Number
Current Odometer Reading
*
Owner / Operator Contact
Owner / Operator Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Inspection Details
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspection Station or Location
*
Inspection Type or Test Method
*
Please Select
Idle Test
Loaded Mode Test
On-Board Diagnostics (OBD) Check
Dynamometer Test
Visual Inspection
Other
Inspector Name or ID
Outcome Status
*
Failed Emissions Inspection
Failure Code or Report Number
Failure Reasons and Diagnostic Results
Failed Emissions Component(s)
*
High hydrocarbons (HC)
High carbon monoxide (CO)
High nitrogen oxides (NOx)
Evaporative system leak
Malfunctioning oxygen sensor
Catalytic converter issue
Fuel cap issue
Incomplete readiness monitors
Exhaust leak
EGR system issue
Other
Observed Symptoms
Diagnostic Trouble Codes or Fault Categories
Failed Test Measurements
*
Rows
Measured Value
Result
Hydrocarbons (HC)
1
2
Carbon Monoxide (CO)
3
4
Nitrogen Oxides (NOx)
5
6
Evaporative leak test
7
8
Readiness monitors
9
10
Was the Check Engine Light on?
*
Yes
No
Unknown
Additional Diagnostic Notes
Maintenance, Repairs, and Corrective Action
Prior maintenance or repair work related to the failure
Parts replaced
Air filter
Oxygen sensor
Catalytic converter
Spark plugs
Fuel cap
Mass air flow sensor
EGR valve
Other
Repairs recommended or actions planned
*
Diagnose emissions system
Replace faulty sensor
Repair exhaust leak
Service ignition system
Perform tune-up
Reset codes and retest
Schedule reinspection
Other
Repair shop name if already scheduled
Estimated completion date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Corrective action notes
Reinspection and Follow-Up
Will the vehicle be reinspected?
*
Yes
No
Undecided
Preferred reinspection date and time window
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Follow-up status
*
Please Select
Pending
Scheduled
Completed
Not required
Unable to complete
Other
Upload supporting documents
Upload a File
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Additional notes
Submit Report
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