COS Vehicle Mileage Form
COS Vehicle Mileage Form
Please complete at time of travel
Driver's Name
Driver's Name
*
First
Last
Driver's email
*
PI or Instructor Name
PI or Instructor Name
*
First
Last
Has everyone in the vehicle filled out the Assumption of Risk form?
*
Has everyone in the vehicle filled out the Assumption of Risk form?
Yes
Click Yes if you are a BSSF Staff member
Click Yes if you are a BSSF Staff member
Yes
Vehicle used
*
Vehicle used
BIO 9 - Suburban (8 passenger)
BIO 10 - Savana (12 passenger)
BIO 15 - Transit (12 passenger)
BIO 8 - F-150/Truck (4 passenger)
COS01- Dodge Truck (5 passenger)
Why are you taking the vehicle out?
Why are you taking the vehicle out?
Gas
Motor Pool/Maintenance
Car Wash
Other
Other
Are you leaving or returning to campus?
*
Are you leaving or returning to campus?
Leaving campus
Returning to campus
Mileage out
*
Mileage in
*
Did your route incur any tolls?
*
Did your route incur any tolls?
No
Yes
Tolls incurred:
*
Tolls incurred:
Midtown Tunnel
Downtown Tunnel
Chesapeake Bay Bridge Tunnel
Coleman Bridge
Other
Other
Is this for....
*
Is this for....
Research
Teaching Course
Did you encounter or notice any mechanical issues? Ex. windshield wipers or windows not working, weird noise, etc.