Vehicle Interlock Inspection Report Form
Complete this form to document the inspection of a vehicle's interlock system.
Vehicle Make and Model
*
Vehicle License Plate Number
*
Date of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Full Name
*
First Name
Last Name
Interlock Device Serial Number
*
Inspection Checklist
*
Rows
Pass
Fail
N/A
Device securely installed
1
2
3
Device powers on correctly
4
5
6
Device records breath samples
7
8
9
No signs of tampering
10
11
12
Warning indicators functional
13
14
15
Comments or Additional Findings
Inspector Signature
*
Submit Inspection Report
Submit Inspection Report
Should be Empty: