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Brake System Evaluation Customer Diagnostic Survey Form
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Customer Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
License Plate #
Your answer
VIN
Your answer
Concern is Occurring...
Always
Sometimes
Rarely
Clear selection
Are the Dash Warning Lights On
Brake Light
ABS Light
Traction Control Light
Other:
Clear selection
Are the Brakes Making Noise
Squeaking
Squealing
Grinding
Rubbing
No Noise
Clear selection
When the Concern Occurs
Slowing to brake
Hard/sudden braking
Releasing the brake
Turning left
Turning right
Turning & braking
In the morning/first drive of the day
Clear selection
How Does the Brake Pedal Feel
Too soft
Too hard
Goes to the floor
Shutters under load
Shutters at high speed
Pulsation in the brake pedal
Pulsation in the steering
Pulsation in the seat
Clear selection
If shutters at high speed, at which speed does this begin? (km/hr)
Your answer
Outside Temperature
Cold
Warm
Hot
Wet
Dry
Clear selection
The Concern Started
MM
/
DD
/
YYYY
Describe the Concern
Your answer
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