Vehicle Sign-Out Sheet for NEMT Vans: Who Had Which Van, Keys, Fuel Card, and Tablet

Your GPS knows where every van is. It does not know who was driving, which fuel card was in the console, or which tablet with the day’s manifest left the office. This sheet answers those questions in one line per handoff, written at the dispatch desk when the keys go out and again when they come back.

It does not repeat the daily pre-trip inspection, which records the van’s condition, or the vehicle fuel log, which records each fill-up. It ties each van to a person for a stretch of time, so the trip log, the fuel log, and any ticket in the mail all point to the same driver.

How to use this template

1. Fill in the equipment list once. Part 3 gives every key set, fuel card, tablet or phone, and toll tag an ID and a home van. Update it whenever you add or retire anything.
2. Keep the sheet where the keys live. Use one page per week on a clipboard at the key box or the dispatch desk. Only the dispatcher on duty, or an owner, hands out keys.
3. Write the line before the van leaves. The driver prints their name. The dispatcher writes the time, the odometer reading, the fuel card and tablet IDs, and whether the pre-trip inspection was done, then initials. If the inspection found a safety defect, the van stays parked and gets no line.
4. Close the line when the van comes back. Write the time in, the odometer in, Y only when the keys, card, and tablet are all back, and the dispatcher’s initials. When a van changes drivers mid-day, close the first line and start a new one. Never cross out a name.
5. Run the end-of-day check in Part 5. Count keys, cards, and devices against Part 3. Every open line is either a van out overnight, listed with its address, or a problem for Part 4.
6. Act on anything missing that day. Shut off a lost fuel card, lock or wipe a lost tablet, and write both in Part 4.
7. File each week’s sheet with that week’s trip logs. When a broker questions a trip, a toll notice arrives, or your tax preparer asks for each van’s miles, the answer is on the sheet for that date.

The template

Part 1: Sheet details

Field	Entry
Company name
Week of (Monday’s date)
Yard or office address
Where keys, cards, and tablets are kept when not in use
Dispatchers who may sign vans out (names and initials)
Who to call about a lost card or device, and the number

Part 2: Sign-out log

Date	Van	Driver (print)	Time out	Odometer out	Fuel card and tablet IDs	Pre-trip done (Y/N)	Time in	Odometer in	Keys, card, and tablet back (Y/N)	Initials out and in

Part 3: Equipment list

Item	ID or last 4 digits	Home van	Serial number or phone number	Passcode and encryption on (Y/N, devices only)	Notes
Key set
Key set
Spare key set (stays in the office)
Fuel card
Fuel card
Tablet or phone
Tablet or phone
Toll tag
Toll tag

Part 4: Missing items and problems

Date	Item and ID	Van	Last person on the sheet	What happened	What was done (card shut off, device locked or wiped, reported)	Closed (date and initials)

Part 5: End-of-day check

Check	Answer
Every line in Part 2 is closed, or listed below as out overnight
Keys in the box match Part 3
Fuel cards in the box match Part 3
Tablets and phones on charge match Part 3
Vans out overnight: van, driver, and address
One-way commutes to add to each driver’s pay record
Problems moved to Part 4
Checked by, and time

Example: a van swap in the middle of a day

These are example entries. On a Tuesday, Van 2’s ramp stops deploying at a dialysis pickup. Dispatch calls the driver, D. Ruiz, back to the yard, and she takes Van 5, which M. Lee has just returned.

Van and driver	Out (time, odometer)	In (time, odometer)	Miles
Van 5, M. Lee	6:30 a.m., 61,301	10:58 a.m., 61,433	132
Van 2, D. Ruiz	6:10 a.m., 48,210	10:52 a.m., 48,297	87
Van 5, D. Ruiz	11:05 a.m., 61,433	4:40 p.m., 61,540	107

• No overlap. Ruiz closed Van 2 at 10:52 before taking Van 5 at 11:05, and Lee had Van 5 back at 10:58. If the day’s trip records put Ruiz in Van 5 at 10:45, that is the overlap a broker counts against you, and you fix the record before you bill.
• The odometers chain. Van 5’s reading when Lee brought it in (61,433) is its reading when Ruiz took it out. A gap between the two means someone drove the van without a line.
• Arizona would want two report pages. If Ruiz had carried one rider in both vans that day, AHCCCS wants a separate Daily Trip Report page for each vehicle.
• The ramp failure goes elsewhere. The defect belongs on the inspection form and in the vehicle maintenance log, not on this sheet.

Why brokers and states care who drove which van

Every trip record names a driver and a vehicle, and NEMT trip documentation covers the full list of what a record needs. The sign-out sheet is the paper that shows those two names were right.

• Arizona. AHCCCS’s Fee-for-Service manual, Chapter 14 (revised July 31, 2026), requires each Daily Trip Report to name the driver and identify the vehicle by the state it is licensed in, its fleet or plate number, its make, and its color. A driver who uses more than one vehicle on the same date of service starts a new report page for each vehicle and numbers the pages.
• MTM Health in Virginia. Its handbook (approved August 10, 2026) scores “overlapping claims”: trips where one driver was in two vehicles, or two drivers were in one vehicle, at the same time. The standard is under 0.99%, and missing a standard can bring a performance improvement plan, liquidated damages, or removal from the network. Its rule on keeping to the assigned mode of transport also warns that substituting vehicles may result in non-payment or corrective action. It charges 2 points for each expired credential of a driver or vehicle used, and 3 points for using a driver, attendant, or vehicle never credentialed in MTM’s system.
• Colorado. HB26-1328, in effect since July 1, 2026, tells the state Medicaid agency to adopt rules requiring providers, the broker, or both to use digital dispatch software that automatically records the driver and the vehicle on every trip (C.R.S. 25.5-1-802(10)(k)). See the Colorado NEMT law for the rest of it.

Check each day’s sheet against that day’s trip records before you send claims. A van that left with one driver and shows up on a trip with another is easier to explain the same week than in an audit.

Tablets and phones: HIPAA’s device record

If your company is a HIPAA covered entity, or a business associate of a broker or health plan, the Security Rule’s device and media controls reach every tablet and phone that holds rider information. HIPAA for NEMT explains when HIPAA applies to you.

• The standard. You need policies for hardware and electronic media holding electronic rider information as they come into and leave your facility, and as they move inside it (45 CFR 164.310(d)(1)). A tablet with the day’s manifest that leaves the office every morning is exactly that.
• The accountability record. The rule’s accountability specification asks you to keep a record of the movements of that hardware and media and the person responsible for it (45 CFR 164.310(d)(2)(iii)). The tablet column in Part 2 and the list in Part 3 are that record.
• Addressable, not optional. For an addressable specification, you assess whether it is reasonable and appropriate for you. If it is, you put it in place. If not, you write down why and use an equal alternative (45 CFR 164.306(d)(3)).
• Six years. Documentation the Security Rule requires is kept for 6 years from the date it was made or last in effect, whichever is later (45 CFR 164.316(b)(2)(i)). If the sheet is your device record, keep it that long.
• When a device goes missing. Breach notice duties cover only “unsecured” information, meaning information not made unusable or unreadable by a method HHS names in its guidance (45 CFR 164.402). Encryption is the usual way, and the NEMT HIPAA policy covers the device settings. Record every lost device in the HIPAA breach log as well as in Part 4.

Drivers’ own phones never pass through the key box, so they need their own controls. The HIPAA risk assessment is where you list them.

Miles, take-home vans, and IRS records

IRS Publication 463 (2025 edition, updated April 30, 2026) lists what car expense records must show, including the mileage for each business use, the total miles for the year, the date of each use, and its business purpose. The odometer readings out and in give you each van’s miles for each driver and day.

• Written at the time. A log counts as made at or near the time of use when you write it with full knowledge of the details, and a log kept weekly qualifies (26 CFR 1.274-5T(c)(2)(ii)(A)).
• Rider details stay elsewhere. Confidential information, such as a place or business purpose, need not appear on a vehicle log if it was recorded at the time somewhere else and is available to the IRS (26 CFR 1.274-5T(c)(2)(ii)(D)). Your trip logs are that record, which is why this sheet has no rider column.
• Form 4562 asks for vehicle use. Part V (2025) asks for each vehicle’s business, commuting, and other personal miles, and the instructions say employees must give that information to the employer for vehicles provided to them. Line 40 lets an employer that provides more than five vehicles to employees who are not 5% owners or related persons skip those per-vehicle questions, if it gets use information from those drivers and keeps it. An employer may rely on adequate records its drivers keep, and must keep a copy (26 CFR 1.274-5T(e)(2)(ii)).
• Take-home vans. Part 5 lists every van out overnight. If you value take-home use with the commuting rule in Publication 15-B (2026), which needs a written policy that allows commuting and no other personal use, each one-way commute is worth $1.50, which goes in the driver’s wages unless the driver pays it back. The company vehicle use policy sets out the two written policies the IRS accepts, and the NEMT mileage log splits business, commuting, and personal miles.

A written policy that bans all personal use only works for vans kept at your business when they are not working, and the rule asks for evidence that they were (26 CFR 1.274-6T(a)(2)). The end-of-day check is that evidence.

Tickets, tolls, and camera notices: naming the driver

Florida mails toll citations and red light camera notices to the van’s registered owner, which is your company, not the driver. Its deadlines are short, and the notice can arrive weeks after the drive, so the sheet has to tell you who had the van at an exact minute in the past.

• Tolls. Under Florida Statutes 316.1001 (2026), the owner is liable for a toll citation unless the van was in another person’s care, custody, or control at the time. To show that, you send the issuing agency an affidavit within 14 days after the citation is issued, with that person’s name, address, date of birth, and driver license number if known. The agency has up to 14 days after issuing the citation to mail it, so the clock may be nearly out when it arrives. A false affidavit is a second-degree misdemeanor, and outstanding toll violations reported to the state can block a plate renewal.
• Red light cameras. Under Florida Statutes 316.0083 (2026), the notice of violation is mailed within 30 days after the violation, and it gives you 60 days to pay the $158 penalty, send an affidavit, or ask for a hearing. If a citation follows, an affidavit naming the person who had the van, with the same details, is due within 30 days after the citation is issued.

The driver’s date of birth and license number are in the driver qualification file. Other states set their own forms and deadlines, so read each notice’s deadline the day it arrives. List every toll tag in Part 3, so each charge on the toll statement matches a van, and the van matches a driver. Who pays for tickets and tolls, and what you may take from a paycheck, belongs in Part 6 of your company vehicle use policy.

Fuel cards and keys

Give each fuel card a home van and keep it with that van’s keys. When the fuel log’s month-end match turns up a charge with no fill-up line, the sign-out sheet shows who held that card on that day, so you can ask the right person the same week.

Keep one spare key set per van in the office, listed in Part 3 and never handed out without a line in Part 2. A van whose keys are in a driver’s pocket overnight is a van out overnight, so it belongs in Part 5 with its address, and your insurance agent should know where it sleeps.