Maintenance Survey

This form is used to submit Maintenance Conversations pertaining to an employee (any employee, not just a Foreman) who notices a maintenance issue on something they are driving, operating, towing, etc. This form is also used by leaders to alert and resolve any issues relating to, but not limited to, all maintenance matters.

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Reporting person’s name: *

Your foreman’s name: *

BCI, BRM, or UCS number of the truck, trailer, equipment, etc: *

Reporting person’s contact number: *

Your current location (city): *

Date of Incident: *

Description of the problem you’re having

Add a description of what you see or hear. For example: the brakes are squeaking; the skid loader is due for a service soon; the right front tire is flat; the windshield wipers are torn; the heater isn’t working, etc.

Can you fix the problem yourself? *

Have you noticed a marker light is out or your wiper blade is torn? If given the bulb or wiper blade, could you replace it when you get back to the shop?

Does this problem make the equipment unserviceable? *

Meaning, is it now unusable for your job today?

Does this problem require immediate maintenance tech intervention, or can it wait until it gets back to the shop today/the next time it is brought back to the shop? *

If a maintenance tech is to be dispatched, please give a specific location of where the broken equipment is located:

Please find an address closest to where the equipment is. If you’re not near a physical address, find the nearest cross streets or landmark (i.e. next to the Sunoco gas station on Main St) and explain the location.

Maintenance Survey

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