Turn ON ____

Does the Transmission Make Noise — Identify All That Apply:
Whine____ Rattle ____ Groan ____ Clunk ____ Buzz ____ Slam
____ Other (Describe) ____________________

Operating Conditions — Check All That Apply
When Did the Concern Start ____

How Often Does it Occur ____

How Long Does it
Last ____

Driving Conditions — Check All That Apply
No Throttle ____

Wide Open
Throttle ____

Light Throttle ____

Medium Throttle ____

Hard Throttle ____

At Idle ____

Starting ____

Decelerating ____

When Shifting ____

Up Hill ____

Down Hill ____

During Braking ____

Highway ____

City ____

Towing ____

Stop and Go ____
Only With A/C
ON ____

Cruising Steady at ____ MPH Cruising Steady at
____ km/h

Cruising Between ____ MPH and ____ MPH
Cruising Between ____ km/h and ____ km/h

At What Engine Temperature Does it Occur — Check All That Apply
When the Engine Temperature is ____ °F When the Engine Temperature is ____ °C Any Temperature ____
Weather and Environment Conditions — Check All That Apply
Ambient Temperature:
Very Cold: Colder Than 0°F (−18°C) ____ Cold: 0°F to 32°F (−18°C to 0°C) ____ Cool: 32°F to 60°F (0°C to 16°C) ____
Warm: 60°F to 80°F (16°C to 27°C) ____ Hot: Hotter Than 80°F (27°C) ____
Any Environment ____

Dry ____

High Humidity ____

Raining ____

Wet Roads ____

Icy Conditions ____

Snowy Conditions ____

Below Sea Level ____

At Sea Level ____

At High Altitudes ____

What Type of Fuel is Used
Biodiesel ____
Brands
(Describe) ____

Diesel #1 ____
Brands
(Describe) ____

Ethanol E85 ____ What Blend / Alcohol % ____
Brands (Describe) ____

Diesel #2 ____
Brands
(Describe) ____
Regular Unleaded
____ Brands
(Describe) ____

Compressed Natural Gas (CNG) ____ Brands
(Describe) ____
Mid Range Unleaded
____ Brands
(Describe) ____

Premium Unleaded
____ Brands
(Describe) ____

When the Gear Selector is in What Range — Check All That Apply
Park / Neutral ____
Reverse ____

Overdrive ____ Tap
Shift ____

Manual Gear Selection:
D1 __ D2 __ D3__ D4 __ D5 __ D6 __ D7 __

Shifting From Gear to Gear — When Does it Occur
Between Shifts From ____ Gear to ____ Gear

Between Shifts From ____ Gear to ____ Gear

Between All Gear
Shifts ____

At What Shift Point Does it Occur — Check All That Apply
Between Shifts From ____ MPH to ____ MPH

Between Shifts From ____ km/h to ____ km/h

This Section Is For Dealer Use Only:
VIN: ____________________
Miles (km): ____________________
Advisor #: ____________________

All Shift Points ____

Technician #: ____________________

Page 14

November, 2012

Bulletin No.: 01-00-89-010J

Customer Concern Verification Sheet — Brakes / Steering / Suspension / Tires / Wheels

Customer Concern Verification Sheet — Brakes / Steering / Suspension / Tires / Wheels
System and Components — Check All That Apply
Antilock Brake System
(ABS) ____

Brakes ____

Park Brake ____

Electronic Suspension
Control ____

StabiliTrak®
System ____

Steering ____

Suspension ____

Tires ____

Tire Pressure Monitor
(TPM) ____

Traction Control
System (TCS) ____

Vehicle Electronic
Stability (VES)
System ____

Vehicle Stability
Enhancement System
(VSES) ____

Wheels ____

Wheel Alignment ____

Other (Describe) ____

Instrument Illumination, Messages and Audible Warnings — Check All That Apply
ABS Yellow Light is
ON ____

Brake Audible Warning
is Active ____

Brake System Red
Warning Light is
ON ____

Service Brakes Soon
Message is
Displayed ____

Service Brake System
Message is
Displayed ____

StabiliTrak® Light is
ON ____

StabiliTrak® OFF
Message is
Displayed ____

Service StabiliTrak®
Message is
Displayed ____

Service Suspension
System Message is
Displayed ____

Service Traction
Control Message is
Displayed ____

TRAC OFF Indicator is
ON ____

Tire Learning Active
Message is Displayed
Continuously ____

Tire Pressure Monitor
(TPM) Light is ON ____

Service Tire Monitor
System Message is
Displayed ____

Other (Describe) ____

Symptoms — Check All That Apply
Brake Noise:
Chirp_____ Grind_____ Squeak_____ Squeal_____ Other_____
Left Front ____ Right Front ____ Left Rear ____ Right Rear ____

Brake Pedal Exhibits:
Excessive Travel ____ Hard Pedal ____ Soft
Pedal ____

Brake Pulsation When Stopping:
Left Front ____ Right Front ____ Left Rear ____ Right Rear ____

Park Brake:
Does Not Hold Vehicle in Place ____ Will Not
Apply ____ Will Not Release ____

Vehicle Ride Quality:
Rides Hard ____
Rides Soft ____
Poor Steering Wheel
Return After
Cornering ____
Suspension Bottoms
Out ____

Shimmy / Vibration:
Left Front ____ Right Front ____ Left Rear ____ Right Rear ____
Floor ____ Seat ____ Steering Wheel ____

Vehicle Dog
Tracks ____

Vehicle Continues to
Steer in Direction of
Previous Turn ____

Vehicle Wanders to the
Left ____ Vehicle
Wanders to the
Right ____

Steering Wheel is Off
Center ____

High Steering Effort
Required ____

Suspension Noise:
Groan ____ Pop ____ Slam ____ Squeak ____ Rattle ____ Other (Describe) _________

Vehicle Sits Uneven:
Left Front ____ Right Front ____ Left Rear ____ Right Rear ____ Left
Side ____ Right Side ____

Tires Leak Air:
Left Front ____ Right Front ____ Left Rear
____ Right Rear ____ Spare ____

Tires Are Noisy:
Left Front ____ Right Front ____ Left Rear
____ Right Rear ____

Tires Have Uneven Wear:
Left Front ____ Right Front ____ Left Rear ____ Right Rear ____

Vehicle Pulls When Accelerating:
Pulls to the Left ____ Pulls to the Right ____

Vehicle Pulls When Stopping:
Pulls to the Left ____ Pulls to the Right ____ Pulls Side to Side ____

Vehicle Sustained
Road Debris Impact
Damage ____

Vehicle Leans or
Sways in Corners ____

Wheels:
Appearance ____ Bent ____ Damaged ____

Other
(Describe) _________

Bulletin No.: 01-00-89-010J

November, 2012

Page 15

Customer Concern Verification Sheet — Brakes / Steering / Suspension / Tires / Wheels
(cont'd)
System and Components — Check All That Apply
Weather and Environment Conditions — Check All That Apply
Any Environment ____

Cold Days ____

Dry Roads ____

Dusty
Environment ____

Icy Conditions ____

Salty
Environment ____

Snowy
Conditions ____

Wet Roads ____

Hot Days ____
Other (Describe) ____

Operating Conditions — Check All That Apply
When Did the Concern
Start ____

How Long Does it
Last ____

How Often Does it
Occur ____

This Section Is For Dealer Use Only:
VIN: ____________________
Miles (km): ____________________
Advisor #: ____________________

What Makes it Start
(Describe) ____

What Makes It Stop
(Describe) ____

Technician #: ____________________

Page 16

November, 2012

Bulletin No.: 01-00-89-010J

Customer Concern Verification Sheet — Engine Driveability

Customer Concern Verification Sheet — Engine Driveability
Symptoms — Check All That Apply
Backfire (Popping Noise):
From the Tail Pipe ____ From Under the
Hood ____

Does Not Crank ____

Cranks But Does Not
Start ____

Difficulty When Refueling the Vehicle ____ Fuel
Odor When Refueling the Vehicle ____

Cranks With a Hard Start ____ Cranks With a
Very Long Time to Start ____
Engine Continues to Run After Key is Turned
OFF:
All the Time ____ Sometime ____

Engine Noise:
Bang ____ Buzz ____ Chirping / Squeal ____ Clunk ____ Groan ____ Hammer ____ Ping / Detonation / Spark Knock
____ Rattle ____ Whine ____ Other (Describe) ______________
Engine Performance:
Buck ____ Chuggle ____ Hesitation ____ Jerk ____ Sag ____ Skip ____
Engine Speed
Fluctuates Without
Moving the
Accelerator ____

Stumble ____

Surge ____

Engine Stalls ____

Exhaust Smells Like
Sulphur (Rotten
Eggs) ____

Exhaust is Smoky ____

Fuel Economy:
Poor in City Driving ____ Poor in Highway Driving ____ What is the
Reported Fuel Economy ____

Idle is Rough ____
Idle Searches ____

Idle is Too Low ____
Idle is Too High ____

Misfire ____

Other (Describe) _____

Engine Runs Hot ____

Increased Engine
Coolant
Consumption ____

Increased Engine Oil
Consumption ____

Low Power ____

Illuminated Indicator Lights and/or Driver Information Center (DIC) Messages Displayed — Check All That Apply

Check Engine Light is
ON ____

Driver Information
Center (DIC) Messages
Are Displayed
(Describe) ____

Malfunction Indicator
Light is ON ____

Reduced Engine
Power Message is
Displayed ____

Service Engine Soon
Light is ON ____

Other Indicator Lights are Illuminated (Describe) ___________________
Operating Conditions — Check All That Apply
When Did the Concern Start ____

Does the Concern Go
Away ____

How Long Does it
Last ____

How Often Does it
Occur ____