Attachment E - Trip ticket.pdf
PDF 195 KB Posted
- Solicitation number
- 75H70424Q00034
About this file
This document is a Trip Ticket, which is a form used to record the use of a government-owned or leased vehicle. The form includes instructions for the driver, certification that the vehicle will be used for official government business only, and fields to record details such as the driver's name, vehicle information, destination, time of use, mileage, and any accidents or incidents.
The related federal contract opportunity is for a Non-emergency Medical Transportation Program for the Shinnecock Indian Nation. The purpose is to provide non-emergency medical transportation services through a program of day-to-day operations. This is a 100% Small Business Set Aside solicitation, with questions due by 05/30/2024. The Department of Health and Human Services Indian Health Service is the procuring agency.
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Text version
Motor Vehicle Trip Ticket Read Instructions to Operators, below.
INSTRUCTIONS Certification·: Receipt of vehicle acknowledged, I certify that this vehicle will be used for OFFICIAL GOVERNMENT BUSINESS ONLY You are responsible for reporting vehicle defects and accidents immediately.
NAMES OF DRIVER DATE VEHICLE TAG NO.
DESTINATION TYPE OF VEHICLE NEEDED
SIGNATURE OF AUTHORIZING OFFICIAL:
Date Returned Date Issued
TOTAL DAYS
IN USE
Was the vehicle involved in an
“I have authorized the driver signing below to use this vehicle for official business only, and certify that funds are available for this purpose.”
Time In Time Out
TOTAL
HOURS
COMMENTS
PHONE NO.
AM
PM
AM
PM
IC
Mileage In Mileage Out
TOTAL
MILEAGE
accident while in your custody? YES NO
SIGNATURE OF DRIVER: “This vehicle will be used for official government business only.”
FOR TRANSPORTATION BRANCH USE ONLY
“C” if credit CUSTOM CHARGE Check contents of vehicle: SIGNATURE OF DISPATCHER
Jack Lug wrench Spare tire Credit card
Special Instructions: Shuttle Run:
8:00am patients 12:30pm patients 2:30pm patients
Operators Daily Maintenance:
Before Operation: Check fluid levels-running lights-tires-damages----- During
Operation: Check instrument panel-listen for unusual noises---- After Operation:
Re-fuel if needed-take out all trash-----
Wash and Clean Vehicle:
8:00am patients 12:30pm patients 2:30pm patients
File details come from the government source that posted it. Updated .