TB 11-6115-741-24
EQUIPMENT INSPECTION AND MAINTENANCE WORKSHEET
For use of this form, see DA PAM 738-750 and 738-751; the proponent agency is DCSLOG
1. ORGANIZATION
2. NOMENCLATURE AND MODEL
3.
4a. MILES
b. HOURS
c. ROUNDS
d. HOT
5. DATE
b. TYPE INSPECTION
REGISTRATION/SERIAL/NSN
FIRED
START
7.
APPLICABLE REFERENCE TM NUMBER
TM NUMBER
TM DATE
TM NUMBER
TM DATE
COLUMN a - Enter TM item number.
COLUMN d - Show corrective action for deficiency or
shortcoming listed in Column c.
COLUMN b - Enter the applicable condition status symbol.
COLUMN c - Enter deficiencies and shortcomings.
COLUMN e - Individual ascertaining completed
corrective action initial in this column.
STATUS SYMBOLS
"X" - Indicates a deficiency in the equipment that places
DIAGONAL "(/)" - Indicates a material defect other
it in an inoperable status.
than a deficiency which must be corrected to increase
efficiency or to make the item completely serviceable.
CIRCLED "X" - Indicates a deficiency, however, the
equipment may be operated under specific limitations as
LAST NAME INITIAL IN BLACK, BLUE-BLACK INK,
directed by higher authority or as prescribed locally, until
OR PENCIL - Indicates that a completely satisfactory
corrective action can be accomplished.
condition exists.
HORIZONTAL DASH "(-)" - Indicates that a required
FOR AIRCRAFT - Status symbols will be recorded in red.
inspection, component replacement, maintenance operation
check, or test flight is due but has not been accomplished,
or an overdue MWO has not been accomplished.
ALL INSPECTIONS AND EQUIPMENT CONDITIONS RECORDED ON THIS FORM HAVE BEEN DETERMINED
IN ACCORDANCE WITH DIAGNOSTIC PROCEDURES AND STANDARDS IN THE TM CITED HEREON.
8a. SIGNATURE (Person(s) performing
8b. TIME
9a. SIGNATURE (Maintenance Supervisor)
9b. TIME
10. MANHOURS
inspection)
REQUIRED
TM
INITIAL WHEN
ITEM
STATUS
DEFICIENCIES AND SHORTCOMINGS
CORRECTIVE ACTION
CORRECTED
NO.
b
c
d
e
a
H-3
