This comprehensive assessment helps evaluate your vehicle's wiper blade condition and overall visibility readiness. Accurate information ensures proper safety recommendations. Fields marked with an asterisk are mandatory.
Full Name
Email Address
Phone Number
How many vehicles will you be inspecting?
Vehicle Make
Vehicle Model
Vehicle Year
Vehicle Identification Number (VIN) - Optional
Overall satisfaction with current visibility during precipitation
In which weather conditions do you most frequently use your wipers? (Select all that apply)
Light rain
Heavy rain
Snow
Sleet/Ice
Fog/Mist
Dust/Debris
Bug splatter
Tree sap/Pollen
How often do you typically use your windshield wipers?
Daily
Several times per week
Weekly
Only during seasonal weather
Rarely
Have you experienced any visibility-related safety concerns in the past 6 months?
Please describe the safety concern(s) and the circumstances:
Do you currently have any known issues with your wiper system?
Describe the known issues:
Inspect each wiper blade position carefully. For each vehicle, evaluate the wipe quality, fluid level, and spray nozzle functionality. This table is the core of your visibility assessment.
Wiper Blade & Washer System Inspection
Vehicle Name/ID | Wiper Blade Position | Wipe Quality | Washer Fluid Reservoir Level | Spray Nozzle Aim | Last Inspected Date | Urgency for Replacement | ||
|---|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | G | ||
1 | Primary Vehicle | Driver Side | 🟡 Streaking/Lines | Half | Covers Windshield | 1/15/2024 | ||
2 | Primary Vehicle | Passenger Side | 🟢 Crystal Clear | Half | Sprays Too Low | 1/15/2024 | ||
3 | Primary Vehicle | Rear Window | 🔴 Chattering/Skipping | Empty/Light On | Clogged/No Spray | 1/15/2024 | ||
4 | ||||||||
5 | ||||||||
6 | ||||||||
7 | ||||||||
8 | ||||||||
9 | ||||||||
10 |
Based on your inspection above, provide additional details about wiper blades that showed less-than-perfect performance.
Did any wiper blade exhibit streaking or lines during operation?
Which position(s) and describe the pattern (e.g., vertical lines, horizontal smears, patchy areas):
Did you observe any chattering, skipping, or bouncing of the wiper blades?
When does this occur?
At low speeds
At high speeds
When dry
When wet
Consistently
Is there visible physical damage to any rubber blade (tearing, cracking, splitting)?
Describe the damage and location on the blade:
When were the current wiper blades installed?
Brand and model of current wiper blades
Type of wiper blade currently installed?
Conventional frame-style
Beam/Flat blade
Hybrid
Winter/snow blade
OEM Original
Unknown
Do you apply any protective treatments to your windshield (e.g., rain repellent, ceramic coating)?
What product do you use and how often?
What type of washer fluid do you primarily use?
All-season standard blue
De-icer winter formula
Bug remover summer formula
Water only
Water with detergent
Concentrated mix
Don't know
Have you noticed the washer fluid reservoir emptying faster than expected?
Estimate how often you refill and any signs of leaks:
Have you ever attempted to clean or unclog the spray nozzles?
What cleaning method did you use?
Pin/needle clearing
Compressed air
Vinegar solution soak
Commercial cleaner
Removed and soaked
Other
Do all washer fluid spray nozzles produce an even spray pattern?
Describe which nozzles are problematic and the specific issue:
Rate the overall effectiveness of your washer system in removing debris
Very Poor
Poor
Fair
Good
Excellent
How many times per week do you typically use the washer fluid spray?
What is your primary climate zone?
Tropical (hot, humid)
Arid (hot, dry)
Temperate (moderate)
Continental (cold winters, hot summers)
Polar (cold, icy)
High altitude
Is your vehicle primarily parked outdoors (exposed to sun and elements)?
On average, how many hours per day is it exposed to direct sunlight?
Which environmental factors frequently affect your windshield? (Select all that apply)
Intense UV/sun exposure
Salt air/coastal environment
Road salt/de-icing chemicals
Sand/dust storms
Industrial fallout
Tree sap/pollen
Bird droppings
Insects/bugs
Ice/snow accumulation
Do you use a windshield sun shade when parked?
Why not?
Forget to use it
Too cumbersome
Don't think it's necessary
Don't own one
Park in shade/garage
Average annual mileage/kilometers driven
Rank these factors by their impact on your wiper blade lifespan (1 = most significant)
Sun UV exposure | |
Frequency of use | |
Extreme temperatures | |
Road debris/sand | |
Chemical exposure (salt, bugs) | |
Quality of wiper blades | |
Improper installation |
Date of last complete wiper blade replacement
How many months do your wiper blades typically last before needing replacement?
Who typically performs your wiper blade replacement?
Self (DIY)
Professional mechanic
Quick lube shop
Dealership
Friend/Family member
Never replaced
Average amount spent on a pair of wiper blades
Do you keep spare wiper blades in your vehicle?
Where do you store them?
Have you ever experienced wiper blade failure during a critical driving situation?
Describe the situation and outcome:
Do you perform regular visual inspections of your wiper blades (at least monthly)?
What prevents regular inspection?
Forget
Don't know how
Don't think it's important
No time
Difficult to access
Other
Upload recent purchase receipt for wiper blades (optional)
Rate the safety risk level for each driving scenario with your CURRENT wiper condition
Very High Risk | High Risk | Moderate Risk | Low Risk | Very Low Risk | |
|---|---|---|---|---|---|
Driving at highway speeds in heavy rain | |||||
Night driving in drizzle | |||||
Urban driving in light rain | |||||
Rural roads with road spray | |||||
Mountain driving with mixed precipitation | |||||
Emergency maneuvers in wet conditions |
Rate your confidence level (1-5) in each weather condition
Heavy downpour | |
Light mist | |
Snow flurries | |
Slushy road spray | |
Freezing rain | |
Dust storm |
Rate the performance of each wiper blade position
Driver side blade | |
Passenger side blade | |
Rear window blade | |
Headlight wipers (if equipped) |
How do you feel about driving in these conditions with current wipers?
Unexpected rainstorm | |
Nighttime highway | |
Heavy traffic in rain | |
Remote area with no shelter |
How confident do you feel driving in heavy rain with your current wiper system?
Overall rating of your current wiper system reliability
Based on your assessment, what is your timeline for wiper blade replacement?
Immediately (within 24 hours)
This week
Within 2 weeks
Within a month
Next seasonal change
No immediate plan
Are you aware that worn wiper blades can permanently scratch your windshield?
I understand the risk and will prioritize replacement
Would you like to receive automated reminders for future wiper blade inspections?
Preferred reminder interval (in months)
Visual documentation helps provide accurate assessments. Please upload clear photos of any problematic wiper blades or spray patterns. Ensure photos are well-lit and show the specific issue.
Upload photo of driver side wiper blade condition
Upload photo of passenger side wiper blade condition
Upload photo of rear wiper blade condition (if applicable)
Upload photo showing spray nozzle pattern on windshield
Do you have any additional visibility accessories (e.g., heated wiper park area, rain sensor)?
Describe the accessories and their condition:
Any additional notes or concerns about your visibility system not covered above?
Electronic signature confirming the accuracy of this assessment
I consent to receiving maintenance reminders and safety alerts via email
I agree to the terms of service and privacy policy for this assessment
How would you rate this assessment form's thoroughness?
Very Poor
Poor
Average
Good
Excellent
To configure an element, select it on the form.