Form 2432, CLASS and DBMD Children Program Vehicle Evaluation

Instructions

Updated: 11/2017

Purpose

Form 2432 is completed when an individual receiving CLASS Program or Community First Choice (CFC) services requests a modification or an addition to the primary transportation vehicle. The form is used to determine and verify the vehicle meets the criteria described in Appendix II of the CLASS Provider Manual.

The vehicle must be less than five years old and the vehicle mileage must be less than 50,000 miles; or the vehicle must pass an independent inspection performed by an automotive technician certified by The National Institute for Automotive Service Excellence (ASE).

Procedures

When to Prepare

Form 2432 is completed by an automotive technician certified by ASE to document a vehicle is functioning in a manner that allows safe operation.

Form Retention

The direct services agency (DSA) must keep the original copy of the form in the individual's case record and provide a copy to the case management agency.

The DSA must keep this form according to record retention requirements documented in the CLASS Provider Manual.

Detailed Instructions

Is the vehicle Registration Current? – Check “Yes” or “No” to indicate if vehicle registration is current.

Owner’s Name — Enter the registered vehicle owner’s name. If the owner is not the individual enrolled in CLASS, also include the name of the individual enrolled in CLASS program.

License Plate Number — Enter the vehicle license plate information and the state that issued the license plate.

Make, Year, and Model — Enter the vehicle manufacturer name, the model year, and model name of the vehicle.

Mileage — Enter the mileage as shown on the vehicle odometer.

Mechanical Areas — Evaluate each specified mechanical area to determine if each area is functioning sufficiently to allow for safe operation of this vehicle. If an area passes, no comment is necessary. If an area fails, please state specifically the work needed to correct the problem.

Additional comments — Document any additional comments to include overall condition of vehicle, overall vehicle maintenance, and general appearance. Describe any indication vehicle has been involved in an accident or flood.

Signature — Include the ASE certified automotive technician’s signature, the typed or printed name of the certified automotive technician, the ASE certification number in the labeled spaces.

Name of Automotive Repair Shop — Include the name of the automotive repair shops as advertised or displayed for public knowledge, the business phone number, and the signature date

edge, the business phone number, and the signature date.