Access Ability Wisconsin - Outdoors Access 4 All! TM
AAW’s OUTDOOR ALL-TERRAIN WHEELCHAIR (OWC) & TRAILER/CARRIER
OWC CONDITION REPORT (EQUIPMENT CHECK OUT/CHECK IN FORM)
Please refer to the Equipment List to ensure you are checking out the correct equipment with accurate Outdoor Wheelchair(s) OWC # and Trailer # or (Carrier # ________) ___ Equipment Checked Out: OWC#___ (Serial #________) Tlr#__ (VIN#_____________________) | |
Check Out: User/Client & AAW Representative review the above for any damage to items and list:
I have provided a valid driver's license and proof of insurance of the person towing the trailer. I understand that my vehicle insurance covers the trailer and contents when connected to my vehicle. I have read the Owner’s Manual and the operation of the Action Trackchair has been explained, demonstrated and I have test driven; any questions I brought up have been answered. I understand I am to bring the chair and trailer back as I received it, making sure to clean off any debris, sweep out the trailer and bring the OWC back fully charged. ______________________________________ _____________ Customer Signature _____________________ Date ______________________________________ _____________ AAW Representative _____________________ Date | AAW Only Reservation Form
Notes:_____________ |
Check In: User/Client & AAW Representative review equipment checked out listed above for any damaged and dirty items and list:
The chair and trailer have been returned in satisfactory condition, clean and the OWC is fully charged. You have completed and turned in your survey with DNR CID#, provided a picture, and your $50 deposit per OWC has been returned to you. You have your personal items such as a wiring harness adapter, hitch pins/clips, or anything you may have put in the trailer or OWC holders. ___ Yes ___ No: due to dirty ___ No: due to damaged (see items listed above) ______________________________________ _____________ Customer Signature _____________________ Date ______________________________________ _____________ AAW Representative _____________________ Date Notes:___________________________________________________________________ | AAW Only Survey
Deposit
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OWC # - Serial No. | Location | Trailer # - VIN | Location |
Tr#7:- Single trailer to use for event chairs 5NHULT014JA11469 | A-Z | ||
OWC#E2-Badger Left Serial#: T02726 | A-Z | Tr#E1:- Event -5NHULT219HA112170 | A-Z |
OWC#E3-Bdgr Narrow Serial#: 3386 | A-Z | ||
OSC | Tr# E2:-AAW Events - 5NHULT416KA115628 | OSC | |
OWC#E4 - Pink, Right Hand joystick Serial#:1478 OSC | |||
Carrier#1 AZ | |||
OWC#9 or E4 | Middleton - (Orchid Heights) | ||
OWC # - Serial No. | Location | Trailer # - VIN | Location |
OWC#7-BlackSplash Serial#:3384 | Tr#7:- Single trailer to use for event chairs 5NHULT014JA11469 | ||
OWC#5 - Camo Serial#: T02975 | Baraboo | Tr#5:-5NHULT014JA114868 | Baraboo |
OWC#1-Blk Serial#: 1699 | Eagle River, WI | Tr#1 - Steel -542BA0816FB010813 | Eagle River, WI |
OWC#4- BLK/Camo Serial#: T03531 | Hayward / FHNB | Tr#4- 5NULT012JA114870 | Hayward / FHNB |
OWC#6 -CamoLeft Serial#:3385 | Hazel Green / OHEC | Tr#6- 5NHULT014JA114871 | Hazel Green |
OWC#8: BLACK Serial#:T03562 | IL-Rockton | Tr# 8:- Single - 5NHULT019KA115614 | IL-Rockton |
OWC#2- BLK/Camo Serial#: T02163 | La Crosse / NASA | Tr#2 - REEVE -5NHULT013GA110495 | La Crosse/ NASA |
OWC#- _____ Serial#: ______ | OSC | TR#3 - OSC | |
OWC#E1 - WTU Serial#: T02727 | Tr# 9 - Options for Independent Living |
AAW-OWC Condition Report MASTER (Equipment Check Out/In Form) Rev. Feb 2022