Driver Qualifications File DOT Required Contents Driver Qualification Forms: (1) Driver Qualification File folder (1) Application for Employment (1) Medical Examiner’s Certificate (1) Medical Examination Report (1) Certification of Road Test Pocket Card (1) Driver Qualification and identification Certificate Pocket Card (1) Driver Record Card (1) Driver Qualification File Contents Sheet (1) Additional Employment History Information (1) Fair Credit Reporting Act Disclosure Statement (1) Request for Check of Driving Record (1) Record and Certificate of Road Test (1) Record of Violations/Annual Review Certificate (1) Certification of Compliance (1) Driver’s Statement of On-Duty Hours – New Hire (1) Employment Eligibility Verification I-9 (1) Checklist for Qualification of New Drivers Alcohol and Drug Forms: (1) Alcohol & Drug Recordkeeping Log (1) Previous Pre-employment Alcohol & Drug Test Statement (1) Alcohol and Drug Records Request (1) Alcohol and Drug Employee’s Certified Receipt (1) Alcohol and/or Controlled Substance Test Notification (1) Drug Test Results (873-FS-C4) (1) Observed Behavior Reasonable Suspicion Record (1) U.S. Department of Transportation Alcohol Testing Form (1) Federal Drug Testing Custody and Control Form

Safety Performance History: (3) Safety Performance history Records Request (1) Previous Employee Safety Performance History

1

Driver Qualifications You’re Qualified to drive a commercial motor vehicle if you …. • Are at least 21 years old. • Can read, write and speak English well enough to converse, read signs and fill out forms. • Have experience or training to safely operate your vehicle. • Have a valid motor vehicle operator’s license. • Have provided to your employer a list of violations you have been convicted of in the last 12 months. • Pass a required physical exam and are physically qualified to drive. • Have passed a road test. • Are not disqualified to drive a CMV.

Know the requirements to stay qualified! Driver Qualification “Entry-Level Driver Training Requirements,” located in Part 380, Subpart E of the Federal Motor Carrier Safety Regulations (FMCSRs). All entry-level drivers who drive in interstate commerce and are subject to the commercial driver’s license (CDL) requirements must receive training in four areas: • driver qualification; • hours of service; • driver wellness; and • whistleblower protection. An entry-level driver is defined in Sec 380.502 as a driver with less than 1 year of experience operating a commercial motor vehicle with a CDL in interstate commerce. This training will focus on the driver qualification and disqualification requirements as mandated in Part 391 of the FMCSRs. When performing this portion of the training, keep in mind that if a driver possesses a CDL, he/she is also subject to the disqualifications provisions in Sec. 383.51 and can be disqualified for offenses committed in any type of vehicle (work or personal) at any time (this includes off-duty time). See Sec 383.51 of the FMCSRs for complete details. As well as aiding in training entry-level drivers, this training blueprint can be used as a review of the requirements for your veteran drivers. 2

General Qualifications: Section 391.11 of the FMCSRs states that an individual must meet certain requirements in order to operate a commercial motor vehicle (CMV). An individual is qualified if he/she: • is at least 21 years old; • can read, write, and speak English well enough to converse, understand traffic signs, respond to official inquiries, and fill out required reports; • has experience or training to safely operate the type of vehicle he/she drives; • passes a required physical exam and is physically qualified to drive; • has a valid motor vehicle operator’s license; • has provided to his/her employer a list of any violations of traffic laws (other than parking violations) he/she has been convicted of in the last 12 months. • is not disqualified to drive a CMV; and • has passed a road test. He/she must also be able to determine whether the cargo being transported is properly loaded, distributed, and secured. He/she must be familiar with the methods and procedures for securing cargo on the CMV he/she operates. This applies to both goods and passengers. Physical Qualifications: Part 391, Subpart E of the FMCSRs states that an individual may not drive a CMV unless he/she passes a physical exam. A driver must carry a certificate signed by a medical examiner that states he/she is physically qualified. The employer must also keep a copy of this certificate in the driver’s qualification file (per Sec. 391.51 of the FMCSRs). A driver is not qualified to operate a CMV if he/she has: • lost a foot let hand, or arm (and has not been granted a sill performance evaluation (SPE) certificate); • an impairment of a hand, finger, arm foot, or leg which interferes with the ability to perform normal tasks associated with driving a CMV (and has not been granted an SPE certificate); • diabetes requiring insulin for control; • heart disease, which causes chest pain, fainting, or shortness of breath; • chest or breathing problems like chronic asthma, emphysema, chronic bronchitis; • high blood pressure likely to interfere with driving • loss of movement of feeling in part of the body; • any sickness which is likely to cause loss of consciousness or any loss of ability to control a CMV; • any mental problems likely to interfere with the ability to drive a CMV safely; • poor vision that affects the ability to see objects that re far away, objects to the side, or traffic signal colors; 3

• poor hearing • use of certain drugs and dangerous substances, except that the driver may use such a substance or drug if the substance or drug is prescribed by a doctor who is familiar with the driver’s medical history and assigned duties and who has advised the driver that the prescribed substance or drug will not adversely affect his/her ability to safety operate a CMV; or • a current clinical diagnosis of alcoholism. A medical exam, conducted by licensed medical examiner who is familiar with the regulations, is required if the driver; • has not been medically examined and physically qualified to drive a CMV; • has not had a medical exam in the past 24 months; or • has suffered a disease or injury that affected his/her ability to drive a CMV. Driver Disqualification: Under Sec 391.15 of the FMCSRs, a driver is disqualified from driving if he/she is convicted (including forfeiture of bond or collateral) of any of the following while operating a CMV: • driving with an alcohol concentration of 0.04 percent or more, or driving under the influence of alcohol as prescribed by state law, or refusing to undergo testing; • operating und the influence of a controlled substance; • transporting, possessing, or unlawfully using drugs; • leaving the scene of an accident involving a CMV; or • committing a felony involving a CMV. The disqualification period ranges from 6 months to 3 years depending on the severity of the offense and the driver’s previous disqualification record. During a trip, a driver may be placed out of service by an enforcement officer for a certain period of time until a give problem has been corrected. Conviction for violating such an out-of-service order subject the driver to disqualification period. The disqualification period ranges from 90 days to 5 years with penalties for drivers of vehicles carrying passengers or hazardous materials being more severe. Effective September 30, 2002, you can be disqualified — forbidden from operating a commercial motor vehicle (CMV) — if you are convicted of certain traffic violations committed in any type of vehicle, including a family car. Just two speeding tickets in your car could put you face-to-face with unemployment. The offenses that can disqualify you are separated into “major offenses” and “serious traffic violations.” Be sure to steer clear of these offenses when driving any type of vehicle. 4

Major offenses in any type of vehicle that will disqualify a CDL driver include: • Being under the influence of alcohol (as prescribed by state law); • Being under the influence of a controlled substance; • Refusing to take a required alcohol test; • Leaving the scene of an accident; • Using a vehicle to commit a felony; • Using a vehicle in the commission of a felony involving the manufacturing, distributing, or dispensing of a controlled substance; and • Committing two or more serious traffic violations (see below). In addition, CDL holders will be disqualified for the following offenses if the offense was committed while operating a CMV: • Having an alcohol concentration of 0.04 or greater; • Driving a CMV when the driver’s CDL is revoked, suspended, or canceled, or the driver is disqualified from operating a CMV; and • Causing a fatality through the negligent operation of a CMV. The period of disqualification ranges from one year to life (but only 60 – 120 days for serious traffic violations) depending on the type of violation and number of times a driver has been convicted of a certain violation. Serious traffic violations in any type of vehicle that would disqualify a driver include two or more convictions within a three-year period for: • Speeding 15 mph or more above the posted speed limit; • Driving recklessly; • Making improper or erratic lane changes; • Following the vehicle ahead too closely; and • Violating state or local law relating to motor vehicle traffic control (other than a parking violation) arising in connection with a fatal accident. Serious traffic violations in a CMV that would disqualify a driver include two or more convictions within a three-year period for: • Driving a CMV without obtaining a CDL; • Driving a CMV without a CDL in the driver’s possession; and • Driving a CMV without the proper class of CDL and/or endorsements for the specific vehicle group being operated or for the passengers or type of cargo being transported. The period of disqualification for serious traffic violations ranges from 60 days to 120 days depending on the type of violation and the number of times a driver has been convicted of a certain violation.

Drivers Application for Employment 5

Applicant Name ______________________________________________ Date of Application _______________ (print) Company________________________________________________________________________ Address_________________________________________________________________________ City_______________________________ State ______________ Zip_______________________ In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

TO BE READ AND SIGNED BY APPLICANT I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing information in connection with my application. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company. I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and (e). I understand that I have the right to: ●

Review information provided by previous employers;

●

Have errors in the information corrected by previous employers and for those previous employers to re-send the corrected information to the prospective employer; and

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Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot agree on the accuracy of the information.

Signature______________________________________________________ Date ___________________________

FOR COMPANY USE PROCESS RECORD APPLICANT HIRED _______________________________________ REJECTED____________________________________________ DATE EMPLOYED ________________________________________ POINT EMPLOYED ____________________________________ DEPARTMENT ___________________________________________ CLASSIFICATION _____________________________________ (IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE) SIGNATURE OF INTERVIEWING OFFICER _________________________________________________________________________ TERMINATION OF EMPLOYMENT DATE TERMINATED ______________________________ DEPARTMENT RELEASED FROM _______________________________ DISMISSED ______________________ VOLUNTARILY QUIT ________________ OTHER___________________________________ TERMINATION REPORT PLACED IN FILE ______________________ SUPERVISOR _______________________________________

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APPLICANT TO COMPLETE (answer all questions – please print)

Position(s) Applied for ________________________________________________________________________ Name _______________________________________________________Social Security No. _______________ Last First Middle List your addresses of residency for the past 3 years. Current Address ______________________________________________________________________________ Street City _______________________________________ Phone _______________ How Long? ________ State Zip Code yr./mo. Previous Addresses _____________________________________________________________How Long? ________ Street City State & Zip Code yr/mo _____________________________________________________________How Long? ________ Street City State & Zip Code yr/mo _____________________________________________________________How Long? ________ Street City State & Zip Code yr/mo Do you have the legal right to work in the United States? ______________________________________________ Date of Birth _______________________________ Can you provide proof of age? ________________________ (Required for Commercial Drivers) Have you worked for SCREENING SYSTEMS INC. before? _____ Where? _____________________ Dates: From _____________ To ____________________ Rate of Pay _____________ Position_______________ Reason for leaving _____________________________________________________________________________ Are you now employed? _____ If not, how long since leaving last employment? _____________________________ Who referred you? _____________________________________________ Rate of pay expected _______________ Have you ever been bonded? ______________________________Name of bonding company __________________ (Answer only if a job requirement) Have you ever been convicted of a felony? ____________________________________________________________ If yes, please explain fully on a separate sheet of paper. Conviction of a crime is not an automatic bar to employment all circumstances will be considered. _______________________________________________________________________________________________ Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the attached job description]? _______________________________________________________________________________________________ If yes, explain if you wish. _______________________________________________________________________________________________ _______________________________________________________________________________________________ EMPLOYMENT HISTORY All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.) EMPLOYER DATE NAME FROM TO CITY STATE ZIP MO. MO. YR. YR. CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO POSITION HELD WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOTSALARY/WAGE REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES REASON FOR
NO LEAVING 7

EMPLOYMENT HISTORY (continued) EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

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*Includes vehicles having a GVWR of 26,001 lbs. Or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. †The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. 8

ACCIDENT RECORD for the past 3 Years or More (Attach Sheet if more space is needed) IF NONE, WRITE NONE DATES NATURE OF ACCIDENT FATALITIES INJURIES HAZARDOUS (HEAD-ON, REAR-END, MATERIAL SPILL UPSET, ETC.) LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS(other than parking violations) IF NONE, WRITE NONE

LOCATION

DATE

CHARGE

(ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATIONS – DRIVER List all driver licenses or permits held in the past 3 years. STATE LICENSE NO. TYPE DRIVER LICENSES

A. B.

PENALTY

EXPIRATION DATE

Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES __________ NO ________ Has any license, permit or privilege ever been suspended or revoked? YES __________ NO ________ IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS ____________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

DRIVING EXPERIENCE CHECK YES OR NO CLASS OF EQUIPMENT STRAIGHT TRUCK TRACTOR AND SEMI-TRAILER TRACTOR – TWO TRAILERS TRACTOR – THREE TRAILERS MOTORCOACH – SCHOOL BUS MOTORCOACH - SCHOOL BUS OTHER

CIRCLE TYPE OF EQUIPMENT

DATES FROM(M/Y) TO (M/Y)

APPROX. NO. OF MILES (TOTAL)


YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO

LIST STATES OPERATED IN FOR LAST FIVE YEARS: __________________________________________________________________ ___________________________________________________________________________________________________________________ SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS DRIVER: ____________________________________________ WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM? ___________________________________________________ EXPERIENCE AND QUALIFICATIONS – OTHER Show any trucking, transportation or other experience that may help in your work for WASKEY BRIDGES, INC.. ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN) ___________________________________________________________________________________________________________________ EDUCATION CIRCLE HIGHETS GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4 LAST SCHOOL ATTENDED _ (NAME) ___________________________________ (CITY, STATE) ________________________________ TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Signature of Applicant: ___________________________________________________________ 9

USE THIS SHEET FOR ADDITIONAL EMPLOYMENT HISTORY INFORMATION (NOTE: LIST EMPLOYERS IN REVERSE ORDER STARTING WITH THE MOST RECENT) All driver applicants to drive in interstate commerce must provide the following information on all employers during the preceding 3 years. List complete mailing address, street number, city, state and zip code. Applicants to drive a commercial motor vehicle* in intrastate or Interstate commerce shall also provide an additional 7 years’ information on those employers for whom the applicant operated such vehicle. (NOTE: List employers in reverse order starting with the most recent.) EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

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USE THIS SHEET FOR ADDITIONAL EMPLOYEMNT HISTORY INFORMATION (continued) EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

EMPLOYER NAME CITY STATE ZIP CONTACT PERSON PHONE NUMBER WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED
YES
NO WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT? TO THE DRUG AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?
YES
NO

FROM MO.

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*Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 15 or more passengers, or any size vehicle used to transport hazardous materials in a quantity requiring placarding. †The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is designed or used to transport 9 or more passengers, OR (3) is of any size and is used to transport hazardous materials in a quantity requiring placarding. 11

Company Name: _______________________________________________ FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT In accordance with the provisions of Section 604(b)(2)(A) of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (Title II, Subtitle D, Chapter I, of Public Law 104-208), you are being informed that reports verifying your previous employment, previous drug and alcohol test results, and your driving record may be obtained on you for employment purposes. These reports are required by Sections 382.413, 391.23, and 391.25 of the Federal Motor Carrier Safety Regulations.

___________________________________ ________________________________ Applicant’s signature Date

___________________________________ _________________________________ Print Name Social Security number

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I. DRIVER SELECTION FORMS 1.

APPLICATION FOR EMPLOYMENT: (391.21) An employment application must be completed by every applicant seeking to drive a commercial motor vehicle. The application for employment shall be made on a form furnished by the motor carrier. Each application form must be completed and signed by the applicant, and must contain the information as outlined in Section 391.21. Before an application is submitted, the motor carrier shall inform the applicant that the information he/she provides may be used and the applicant’ prior employers may be contacted, for the purpose of investigating the applicant’s background. The form must be retained in the driver’s qualification file for 3 years after the person’s employment by the motor carrier ceases. 2.

ADDITIONAL EMPLOYMENT HISTORY INFORMATIN SHEET: This is a supplemental sheet used to obtain information from driver applicants on all employment as a commercial vehicle driver for the past 10 years. It can also be used to obtain additional past employment history for any job applicant. NOTE: The regulations require a check with employers for the past three years only. 3.

REQUEST FOR CHECK OF DRIVING RECORD: (391.23)(391.25) Each motor carrier is required to investigate the driving record, for the preceding 3 years, of each driverapplicant. The appropriate agency of every state in which the driver held a motor vehicle operator’s license or permit during those 3 years must be contacted. A copy of the response by each state agency showing the driver’s driving record or certifying that no driving record exists for that driver, must be placed in the driver’s qualification file within 30 days of the date employment begins. The responses must be retained in the file for 3 years after employment by the motor carrier ceases. The regulations also require a motor carrier to obtain a driving record on each driver each following year. The record must be kept for 3 years. NOTE: A number of states require their specific form be used in making such inquiries. 4. DRIVER’S PHYSICAL EXAMINATION: MEDICAL EXAMINATIN REPORT and MEDICAL EXAMINER’S CERTIFICATE (391.45) All persons driving a commercial motor vehicle are required to obtain a physical examination at least every 24 months. The examination must be made by a qualified medical examiner and shall be recorded on the prescribed form per Section 391..43. the completed medical exam form shall be retained on file at the office of the medical examiner, A copy of the medical examiner’s certificate shall be retained in the driver qualification file for 3 years from the date of execution. A copy of the certificate is given to the driver to be carried at all times. The examination form contains medical information and should be retained in a confidential manner. NOTE: Only the medical examiner’s certificate is required to be maintained in this file. 5.

RECORD AND CERTIFICATE OF ROAD TEST: (391.31) A road test shall be given by a person who is competent to evaluate and determine whether the person who takes the test has demonstrated that he/she is capable of operating the vehicle, and the associated equipment, that the motor carrier intends to assign him/her. The person who gives the test shall rate the performance of the person who takes it at each operating or activity which is part of the test. After he/she completes the form, the person who gives the test shall sign it. The original copy of the road test is retained in the driver qualification file. Upon successful completion of the road test the person who gave it shall complete a Certificate of Driver’s Road Test. The original shall be retained in the qualification file and the duplicate or card given to the person who was examined. The information must be retained by the motor carrier for the 3 years after the person’s employment by them ceases. 6.

RECORD OF VIOLATION/ANNUAL REVIEW CERTIFICATE: (391.27) At least every 12 months a motor carrier shall require each driver it employs to prepare and furnish it with a list of all violations of motor traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted or on account of which he has forfeited bond or collateral during the preceding 12 months. If the driver has not been convicted of, or forfeited bond or collateral on account of, and violation which must be listed, he/she shall so certify. The motor carrier shall retain the list or certificate or a copy of it in its files as part of the driver’s qualification file. Each motor carrier shall at least once every 12 months review the driving record of each driver it employs to determine whether that driver meets minimum requirements for safe driving or is disqualified to drive pursuant to Section 391.15. The review shall be signed and dated by the review reviewing and the form placed in the driver qualification file. A company card may then be issued to the driver stating the driver’s file has been reviewed and that he/she meets the requirements of part 391. The records may be removed from the driver’s qualification file 3 years after date of execution. 13

7.

DRIVER’S DATA SHEET – FOR NEWLY HIRED DRIVERS: (395.8(j) (2)) Motor carriers, when using a driver for the first time, shall obtain from the driver a signed statement giving the total time on duty during the immediately preceding 7 days and the time at which such driver was last relieved from duty prior to beginning work for such carrier. The driver also provides information regarding other compensated work for any other employers. The hours of on-duty time are retained at the driver’s home terminal until the 20th day of the succeeding calendar month and retained an additional 6 months at the carrier’s principal place of business. 8.

CERTIFICATION OF COMPLIANCE: (383.21, 391.11(b) (7)) No person who operates a commercial motor vehicle shall at any time have more than one driver’s license. The “Certification of Compliance with Driver License Requirements” form asks the driver to certify that he/she meets the signal driver’s license requirement. NOTE: The Certification of Compliance form is not required for DOT compliance. 9.

EMPLOYMENT ELIGIBILITY VERIFICATION: The Immigration Reform and control Act of 1986 requires every American employer to hire only American citizens and aliens who are authorized to work in the United States. Every employer needs to verify employment eligibility of anyone hired after November 6, 1998. The Employment Eligibility Verification (From I-9) must completed.; Examine documentation presented by new employees, record information about the documents on the verification form, and sign the form. The form is to be retained for 3 years or for 1 year past the end of employment of the individual, whichever is longer. (Form No. 91-F) NOTE: The Employment Eligibility Verification (Form I-9) may be maintained in a personnel file. The form is not required by DOT and therefore need not be kept in the driver qualification file. 10. POCKET CARDS: To be completed for items 5 and 6 and given to driver. 11. MEDICAL EXAMINER’S CERTIFICATE: The Medical Examiner’s Certificate needs to be carried by the driver at all times when he/she is driving. II. DRIVER CONTROL FORMS 1. CHECKLIST FOR QUALIFICATINO OF NEW DRIVERS: Use of this form provides a handy checklist for orderly recording of completion of documents. Complete the driver information, name, social security number, and address. Enter the dates the requests were forwarded and then completed for the driver’s qualification file. The supervisor’s signature completes each entry. List other company documents added. Alcohol and controlled substance program documents may be recorded, but must be retained in a separate file if this driver qualification file is not handled in a confidential manner. NOTE: The Checklist for Qualification of New Drivers form is not required for DOT compliance. 2.

EMPLOYEE RECORD CARD: This is a convenient form to summarize key information about the performance of drivers and other employees with respect to accident experience, safety awards, due dates of medical examinations, etc. 3.

FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT: Fair Credit Reporting Act, (Public Law 91-508) as amended by the Consumer Reporting Act of 18996 (Title II, Subtitle D, Chapter I, of Public Law 104-208) the 16-F-A, Fair Credit Reporting Act Disclosure Statement, has been created to comply with new FCRA requirements. It provides a “separate” disclosure statement to all job applicants for which a consumer report (driver’s record) will be requested. It also provides space for the applicant to authorize acquisition of the consumer report, another FCRA requirement. Effective 1/31/1999, written authorization on the 16-F-jA is no longer man dated for drivers’ records. (Form No. 16-F-F) NOTE: The Fair Credit Reporting Act Disclosure Statement is not required for DOT compliance.

14

Q & A: Medical Exam Requirements Q. I am in the process of hiring a veteran driver who possesses a current, valid medical exam certificate/card from a previous employer. Am I required to send the driver for a new physical exam? A. You may accept the certificate/card rather than send the driver in for an additional physical. However, you are not obligated to accept it and may send the driver in for a physical. Keep in mind that an employer who accepts a previous employer’s medical exam certificate/card is taking on any liabilities associated with the physical, including any errors which may have occurred. Q. I have a driver who is returning to duty next week after being hospitalized for a heart condition. Do I have to send him for a new physical? His current medical exam certificate/card has not expired. A. Section 391.45 of the Federal Motor Carrier Safety Regulations (FMCSRs) states that a driver must undergo a medical exam if his ability to perform normal duties has been impaired by physical or mental injury or disease. If the driver’s abilities were not impaired, an examination is not required. However, you, as the motor carrier, may require a driver returning form any illness or injury to undergo a physical exam. Keep in mind, that it is your responsibility to make sure only physical qualified drivers are operating commercial motor vehicles. Q. I have a driver who claims that he must have a copy of the physical exam (long form) in his possession at all times. Is this true? A. No, the driver is not required to carry a copy of the physical form with him at all times. The original of the physical form is retained at the medical examiner’s office. This is found in the instructions to the medical examiner in Sec. 391.43 of the FMCSRs. The driver is only responsible for carrying a legible copy of the medical examiner’s certificate/card on his person per Sec. 391.41. Q. Can a driver carry a photocopy of the medical exam certificate/card. A. Yes, Sec. 391.41 (a) states that a driver must be physically qualified and carry the original or a photographic copy of the medical examiner’s certificate/card on his/her person to demonstrate compliance.

15

A driver can be un-qualified if diagnosed with the below conditions: • Diabetes requiring insulin for control; • Heart disease, which causes chest pain, fainting, or shortness of breath; • Chests or breathing problems like chronic asthma, emphysema, chronic bronchitis; • High blood pressure likely to interfere with driving; • Loss of movement or feeling in part of the body; • Any sickness which is likely to cause loss of consciousness or any loss of ability to control a CMV; • Any mental problems likely to interfere with the ability to drive a CMV safely; • Poor vision that affects the ability to see objects that are far away, objects to the side, or traffic signal colors; • Poor hearing; • Use of certain drugs and dangerous substances, except that the driver may use such a substance or drug if the substance or drug is prescribed by a doctor who is familiar with the driver’s medical history and assigned duties and who has advised the driver that the prescribed substance or drug will not adversely affect his/her ability to safely operate a CMV; or • A current clinical diagnosis of alcoholism. A medical exam, conducted by a licensed medical examiner who is familiar with the regulations, is required if the driver: • Has not been medically examined and physically qualified to drive a CMV; • Has not had a medical exam in the past 24 months; or • Has suffered a disease or injury that affected his/her ability to drive a CMV. Driver Disqualification Under Sec. 391.15 of the FMCSRs, a driver is disqualified from driving if he/she is convicted (including forfeiture of bond or collateral) of any of the following while operating a CMV: • Driving with an alcohol concentration of 0.04 percent or more, or driving under the influence of alcohol as prescribed by state law, or refusing to undergo testing: • Operating under the influence of a controlled substance; • Transporting, possessing, or unlawfully using drugs; • Leaving the scene of an accident involving a CMV; or • Committing a felony involving a CMV. The disqualification period ranges form 6 months to 3 years depending on the severity of the offense and the driver’s previous disqualification record.

16

During a trip, a driver may be placed out of service by an enforcement officer for a certain period of time or until a given problem has been corrected. Conviction for violating such and out-of-service order subjects the driver to a disqualification period. This disqualification period ranges from 90 days to 5 years with penalties for drivers of vehicles carrying passengers or hazardous materials being more severe.

17

RECORD OF ROAD TEST Driver’s Name____________________________________________ Address ___________________________________________________ License No. __________________________________ State ____ Equipment Driven: Truck Tractor __________ Trailer________________ Checked From ___________________________________ to _________________________________________ Date ___________________ For those items that apply, place a checkmark (√) if driver’s performance is satisfactory, mark with an X if driver’s performance is unsatisfactory. Explain unsatisfactory items under Remarks. Use no applicable (NA) for items that do not apply

PART 1- PRE-TRIP INSPECTION AND EMERGENCY EQUIPMENT Checks general condition approaching unit Looks for leakage of coolants, fuel, lubricants Checks under hood–oil, water, general condition of engine compartment, steering Checks around unit – tires, lights, trailer hookup, Break and light lines, body, doors, horn windshield wipers Test break action, tractor protection valve, and parking (hand) break Checks horn, windshield wipers, mirrors, emergency equipment: reflectors, flares, fuses, tire chains (if necessary), Fire extinguisher Checks instruments for normal readings Checks dashboard warning lights for proper functioning Cleans windshield, windows, mirrors, lights, reflectors Reviews and signs previous report

______ ______ ______

______ ______

______ ______ ______ ______ ______

PART 2 – COUPLING AND UNCOUPLING Lines up units ______ Connects glad hands to trailer to apply trailer Brakes before coupling ______ Connects glad hands and light line properly ______ Couples without difficulty ______ Raises landing gear fully after coupling ______ Visually checks king pin assembly to be certain of proper coupling ______ Checks coupling by applying hand valve or tractor-protection valve (trailer air supply valve) and gently applying pressure by trying to pull away from trailer ______ Assure that surface will support trailer before uncoupling ______ PART 3 – PLACING VEHICLE IN MOTION AND USE OF CONTROLS: A. ENGINE Places transmission in neutral before starting engine Starts engine without difficulty Allows proper warm-up Understands gauges on instrument panel Maintains proper engine speed (rpm) while driving Does not abuse motor

______ ______ ______ ______ ______ ______

B. CLUTCH AND TRANSMISSION Starts loaded unit smoothly Uses clutch property Times gearshift properly Shifts gears smoothly Uses proper gear sequence

______ ______ ______ ______ ______

C. BRAKES Knows proper use of tractor protection valve Understands low air warning Tests service brakes Builds full air pressure before moving

______ ______ ______ ______

D. STEERING Controls steering wheel Good driving posture and good grip on wheel E. LIGHTS Knows lighting regulations Uses proper headlight beam Dim lights when meeting or following other traffic Adjusts speed to range of headlights Proper use of auxiliary lights

______ ______ ______ ______ ______ ______ ______

PART 4 – BACKING AND PARKING A. BACKING Gets out and checks before backing ______ Looks back as well as uses mirror ______ Gets out and rechecks conditions on long back ______ Avoids backing from blind side Signals when backing ______ Controls speed and direction properly while backing ______ B. PARKING (City) Does not hit nearby vehicles or stationary objects ______ Parks proper distance from curb ______ Sets parking brake, puts in gear, chocks wheels, shuts off motor ______ Checks traffic conditions and signals when pulling out from parked position ______ Parks in legal and safe location ______ C. PARKING (Road) Parks off pavement Avoids parking on soft shoulder Uses emergency warning signals when required Secures unit properly

______ ______ ______ ______

18

PART 5–SLOWING AND STOPPING Uses gears properly ascending Gears down properly descending Stops and restarts without rolling back Tests brakes before descending grades Uses brakes properly on grades Uses mirrors to check traffic to rear Signals following traffic Avoids sudden stops Stops smoothly without excessive fanning Stops before crossing sidewalk when coming out of driveway or alley Stops clear of pedestrian crosswalks PART 6-OPERATING INTRAFFIC PASSING AND TURNING A. TURNING Signals intention to turn well in advance Gets into proper lane well in advance of turn Checks traffic conditions and turns only when intersection is clear Restricts traffic from passing on right when preparing to complete right and turn Completes turn promptly and safely and does not impede other traffic B. TRAFFIC SIGNS AND SIGNALS Approaches signal prepared to stop if necessary Obeys traffic signal Uses good judgment on yellow light Starts smoothly on green Notices and heeds traffic signs Obeys “Stop” signs

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

______ ______ ______

______ ______

______ ______ ______ ______ ______ ______

C. INTERSECTIONS Adjusts speed to permit stopping if necessary _____ Checks for cross traffic regardless of traffic controls _____ Yields right-of-way for safety _____ D. GRADE CROSSINGS Adjusts speed to condition Makes safe stop, if required Selects proper gear and does not shift gears while crossing Knows and understands federal and state rules governing grade crossing

_____ _____ _____

_____

E. PASSING Passes with sufficient clear space ahead _____ Does not pass in unsafe location; hill, curve, intersection _____ Signals change of lanes _____ Warns driver being passed _____ Pulls out and back with certainty _____ Does not tailgate _____ Does not block traffic with slow pass _____ Allows enough room when returning to right lane _____

F. SPEED Speed consistent with basic ability Adjusts speed properly to road, weather, traffic conditions, legal limits Slows down for rough roads Slows down in advance of curves, Intersections, etc. Maintains consistent speed G. COURTESY AND SAFETY Uses defensive driving techniques Yields right-of-way for safety Goes ahead when given right-of-way by others Does not crowd other drivers or force way through traffic Allows faster traffic to pass Keeps right and in own lane Uses horn only when necessary Generally courteous and uses proper conduct

_____ _____ _____ _____ _____

_____ _____ _____ _____ _____

_____

PART 7 – MISCELLANEOUS A. GENERAL DRIVING ABILITY AND HABITS Consistently alert and attentive _____ Adjusts driving to meet changing conditions _____ Perform routine functions without taking eyes from road _____ Checks instrument regularly while driving _____ Willing to take instructions and suggestions _____ Adequate self-confidence in driving _____ Is not easily angered _____ Positive attitude _____ Good personal appearance, manner, Cleanliness _____ Good physical stamina _____ B. HANDLING OF FREIGHT Checks freight properly Handles and loads freight properly Handles bills properly Breaks down load as required C. RULES AND REGULATIONS Knowledge of company rules Knowledge of regulations: federal, state, local Knowledge of special truck routes

_____ _____ _____ _____

_____ _____ _____

D. USE OF SPECIAL EQUIPMENT ( Specify) ______________________________ _____ _______________________________ _____

19

REMARKS: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ GENERAL PERFORMANCE: Satisfactory ________________ Needs Training ____________ Unsatisfactory_____________ QUALIFIED FOR: Truck ______ Tractor-Semitrailer _____

Other ______________________________________________ (Specify)

_______________________________________ Signature of Examiner

20

CERTIFICATION OF ROAD TEST Instructions to Carrier: If the road test is successfully completed, the person who gave it must complete the following certification in duplicate. The original of the signed road test form and the original of the Certification of Road Test shall be retained in the driver qualification file of the person who was examined, and duplicate copies provided to the person examined. Section 391.31 (e) (f) (g) (1) (2) of the Federal Motor Carrier Safety Regulations. Driver’s Name ___________________________________________ Type of Power Unit ________________________________________ Social Security No. _______________________________________ Type of Trailer(s) __________________________________________ Operator’s or Chauffeur’s Lic. No. ______________________ State ______ If Passenger Carrier, Type of Bus________________________ This is to certify that the above-named driver was given a road test under my supervision on _____ 20 ___ consisting of approximately _____ miles of driving. It is my considered opinion that this driver possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above. Signature of examiner _____________________________________ Organization ______________________________________________ Title ___________________________________________________ Address of Examiner ________________________________________

21

REQUEST FOR CHECK OF DRIVING RECORD NOTE TO MOTOR CARRIER: SEE 2ND PAGE FOR STATES THAT ACCEPT THIS FORM. I hereby authorize you to release the following information to __________________________________________ (Prospective Employer) for purposes of investigation as required by Sections 391.23 and 391.25 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from furnishing such information. _________________________________________________________ __________________________________ (Applicant’s Signature) (Date) ……………………………………………………………………………………………..…………………………. In accordance with the provisions of Sections 604 and 607 of the Fair Credit Reporting Act, Public Law 91-508, as amended by the Consumer Credit Reporting Act of 1996 (title II, Subtitle D, Chapter 1, of Public Law 104-208), I hereby certify the following: 1. The consumer (applicant) has authorized in writing the procurement of this report; 2. The consumer (applicant) has been informed in a separate written disclosure that a consumer report may be obtained for employment purposes; 3. The information requested below will be used for a “permissible purpose” (i.e., information for employment purposes) and will be used for no other purpose; 4. The information being obtained will not be used in violation of any federal or state equal opportunity law or regulation; and 5. Before taking an adverse action based in whole or in part on the report the consumer (applicant) will receive a copy of the requested report and the summary of consumer rights as provided with the report by the consumer reporting agency. I also hereby certify that this report request and the above applicant’s release notice meet the definition of “permissible uses” of state motor vehicle records under the provisions of the Driver’s Privacy Protection Act of 1994 (Public Law 103-322, Title XXX Section 300002(a)). ________________________________________________________ _______________________________ (Signature of Requester) (Date) TO: ________________________ ________________________ ________________________ ________________________ DEAR SIR/MADAM:
The following named person has made application with our company for the position of __________________ _________________________. In accordance with Section 391.23, Federal Department of Transportation Regulations please furnish the undersigned with the applicant’s driving record for the past three years.
The following named person is employed with our company in the position of __________________________ _________________________. In accordance with Section 391.25, Federal Department of Transportation Regulations please furnish the undersigned with the employee’s driving record the past year. NAME OF APLIACNT/DRIVER ___________________________________________________________________ ADDRESS _____________________________________________________________________________________ (Number & Street)

(City)

(State)

(Zip Code)

FORMER ADDRESS _____________________________________________________________________________ (Number & Street)

(Number & Street)

(City)

(State)

(Zip Code)

DATE OF BIRTH _____________________ SSN ____________________ LICENSE NO. _________________ REQUESTED BY ____________________________________________ ___________________________________________ (Name of Company) (Typed Name) ______________________________________________________ ____________________________________________________ (Address) (Title) 22

REQUEST FOR DRIVER INFORMATION Most states require their specific form to be used to obtain an individual’s driving record. The following states do not require the use of a state-specific form. This information is current through May 6, 2004, and is subject to change. State/General Contact Information State/General Contact Information District of Columbia Kentucky Department of Adjudication Transportation Cabinet Driving Records Branch Division of Driver Licensing 65 K Street, N.E., room 200 A Fee Accounting Section Washington, DC 20002 200 Mero St. (202) 535-1530 Frankfort, KY 40622 (502)564-6800 Ext. 5358 Florida Maine Bureau of Records Bureau of Motor Vehicles PO Box 5775, MS 90 State House Station 29 Tallahassee, FL 32314-5775 Attn: Driving Records (850) 922-9000 Augusta, ME 04333-0029 (207)624-9000 Ext. 52116 Maryland¹ Hawaii State Motor Vehicle Administration Traffic Violations Bureau Driver Records Unit, Room 145 Abstract Section 6601 Ritchie Highway, N.E. 111 Alakea Street, 2nd Floor Honolulu, HI 96813 Glen Burnie, MD 21062 (808) 538-5530 (410)768-7034/7035 Idaho Minnesota Idaho Transportation Department Department of Public Safety Driver Services Section Driver Compliance PO Box 34 445 Minnesota Street, Suite 180 Boise, ID 83731-0034 St. Paul, MN 55101 (208) 334-8735 (651)296-2023 Indiana North Dakota Bureau of Motor Vehicles Driver’s License and Traffic Safety Division 100 N. Senate Ave., Room N405 State Highway Department Indianapolis, IN 46204 608 E. Blvd. Ave. (317)233-6000, option #2 Bismarck, ND 58505-0178 (701)224-2603 Iowa Rhode Island Iowa Department of Transportation Operator Control Office of Driver Services 286 Main Street Park Fair Mall, 100 Euclid Avenue Pawtucket, RI 02860 PO Box 9204 (401)721-2650 Des Moines, IA 503-9204 (800)532-1121 (515)244-9124 Kansas¹ West Virgina¹ Department of Revenue Department of Motor Vehicles Driver Control Driver Improvement Division, Building 3, Room 124 PO box 12012 1800 Kanawha Blvd., East Topeka, KS 66612 Charleston, WV 25317 (785)296-3671 (304) 558-0238 ¹State-issued form or other form of written request is considered acceptable.

23

Motor Vehicle Driver’s Certification of Compliance with Driver License Requirements MOTOR CARRIER INSTRUCTIONS: The requirements in part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. The requirements in part 391 apply to every driver who operates in interstate commerce and operates a vehicle weighing 10,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding. DRIVER REQUIRESMENTS: parts 383 and 391 of the Federal Motor Carrier Safety Regulations contain some requirements that you as a driver must comply with. These requirements are in effect as of July 1, 1987. They are as follows: 1)

POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license. If you have more than one license, keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYING a license does not close the record in the state that issued it; you must notify the states. If a multiple license has been lost, stolen, or destroyed, close your record by notifying the state of issuance that you no long want to be licensed by that state.

2)

NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 391.15(b) (2) and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the NEXT BUSINESS DAY of any revocation or suspension of your driver’s license. In addition, Section 383.31 requires that any time you violate a state or local traffic law (other than parking), you must report it within 30 days to: 1) your employing motor carrier, and 2) the state that issued your license (If the violation occurs in a state other than the one which issued your license). The notification to both the employer and state must be in writing.

The following license is the only one I will possess: Driver’s License No. _____________________ State ________________ Exp. Date___________ DRIVER CERTIFICATION: I certify that I have read and understood the above requirements. Driver’s Name (Printed): ____________________________________________________________ Driver’s Signature: ______________________________________ Date ______________________ Notes: ____________________________________________________________________________

24

MOTOR VEHICLE DRIVER’S Certification of Violations/Annual Review of Driving Record MOTOR CARRIER INSTRUCTIONS: Each motor carrier shall at least once every 12 months, require each driver it employs to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only) parking of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383. need not repeat that information on this form. DRIVER REQUIREMENT: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond of collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER – CERTIFICATIN OF VIOLATIONS NAME OF DRIVER: (PRINT)

SOCIAL SECURITY NUMBER

HOME TERMIANL (CITY AND STATE)

DRIVER’S LICENSE NUMBER

DATE OF EMPLOYMENT STATE

EXPIRATION DATE

I certify that the following is a true and complete list of traffic violations required to be listed (other than those I have provided under part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

(If you have had no violations, check the following box –
None.) DATE

OFFENSE

LOCATION

TYPE OF VEHICLE OPERATED

_________ _________ _________ _________

______________________ ______________________ ______________________ ______________________

_______________________ _______________________ _______________________ _______________________

_________________________________ _________________________________ _________________________________ _________________________________

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months. Date of Certification ___________________________ Drivers Signature________________________________________ COMPLETED BY MOTOR CARRIER – ANNUAL REVIEW OF DRIVING RECORD MOTOR CARRIER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below.

I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one):
Meets minimum requirements for safe driving


Is disqualified to drive a motor vehicle pursuant to Section 391.15


Does not adequately meet satisfactory safe driving performance Action taken with driver: ____________________________________________________________________________________________________________ ________________________________________________________________________________________________ Reviewed by:

________________________________________ Signature ________________________________________ Printed Name

_____________________________ Motor Carrier Name

________________________________________ Date ________________________________________ Title

______________________________________________________ Motor Carrier Address

MAINTAIN THIS DOCUMENT IN THE DRIVER’S QUALIFICATIN FILE. THIS DOCUMENT MAY BE PURGED AFTER 3 YERS FROM DATE OF EXECUTION.

25

PREVIOUS EMPLOYEE SAFETY PERFORMANCE HISTORY Pursuant to a request for Previous Employee Safety Performance History, Dated ____________________, this response is being provided to the Prospective Employer noted below in compliance with the Department of Transportation regulations, §391.23(g)(1) and §40.321(b).
Corrected Copy, Replaces Response Dated: ____________________________

TO BE COMPLETED BY THE PREVIOUS EMPLOYER DRIVER IDENTIFICATION Name of Previous Employee: _____________________________________________________________
DOT Regulated Driver Social Security No.:_____________________________________ Date of Birth: _____/_____/_____
Non-DOT Regulated Driver Employed from ______________________ to _____________________________ as ___________________________________ PREVIOUS EMPLOYER INFORMATION Company Name: ________________________________________ Phone Number: _____________________________________ Contact Name: __________________________________________ Email: ____________________________________________ Street: ___________________________________________________________________________________________________ City, State, Zip: ___________________________________________________________________________________________ PROSPECTIVE EMPLOYER INFORMATION Company Name: ________________________________________
Mailed, Date: ____________________________________ Attention: ______________________________________________
Faxed, Date: ____________________________________ Street: _________________________________________________
Emailed, Date: ______________________________ City, State, Zip: _________________________________________
Relayed by Phone, Date: __________________________ Name of Person Contacted: ________________________ SAFETY PERFORMANCE HISTORY
There is no safety performance history to report. Driver operated a:
Straight Truck
Tractor-Semitrailer
Bus
Cargo Tank
Doubles/Triples
Other (Specify) ____
Driver did not operate a motor vehicle.
Resignation
Lay Off
Military Duty Reason for leaving employ:
Discharged ACCIDENTS: Date Location No. of Injuries No. of Fatalities Hazmat material Sp 1. __________________________________ _______________ _____________ ________________ 2. _______________ _____________________ _______________ _____________ ________________ 3. _______________ _____________________ _______________ _____________ ________________
No accident register data for this driver.
Enclosed is other accident information pursuant to the employer’s internal policies for retaining minor accident information (§391.23(d) (2) (ii)). DRUG/ALCOHOL TESTING:
Prospective employer did not provide signed release from driver (§391.23(d) (2) (ii)). Under DOT drug and alcohol testing requirements for the past 3 years: Yes No 1. This person was employed in a safety-sensitive function that required alcohol and controlled substances testing specified by 49 CFR part 40 (if NO, skip this section).

2. This person had an alcohol test with a result of 0.04 or higher alcohol concentration.

3. This person tested positive or adulterated or substituted a test specimen for controlled substances.

4. This person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or controlled substance test.

5. This person committed other violations of Subpart B of Part 382, or Part 40.

6. This person violated a DOT drug and alcohol regulation and completed a SAP-prescribed rehabilitation program in our employ, including return-to-duty and follow-up tests. If yes, documentation is enclosed.

7. This person, after successfully completing a SAP’s rehabilitation referral, remained in our employ but subsequently had an alcohol test result of 0.04 or greater, a verified positive drug test, or refused to be tested.

In providing this information, any drug or alcohol testing information obtained from previous employers under §40.25 or other applicable DOT regulations is included. Any other remarks:________________________________________________________________________________________ Signature: _______________________________Title:__________________________ Date: _________________ 26

INSTRUCTIONS FOR COMPLETION OF FORMS ALCOHOL & DRUG RECORDS 1.

PREVIOUS PRE-EMPLOYMENT ALCOHOLAND DRUG TEST STATEMENT: (40.25(j)) Motor carriers must ask employees whether they have tested positive or refused to test on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he/she had a positive test or a refusal to test, the motor carrier must not use the employee to perform safety-sensitive functions until and unless the employee document successful completion of the return-to-duty process. (Form No. 886-FS-C2) NOTE: The Previous Pre-Employment Alcohol and Drug Test Statement is not required for DOT compliance. DRUG AND ALCOHOL RECORDS REQUEST: (40.329)(40.331)(a))(382.405(b) and 9f)) A driver is entitled, upon written request, to obtain copies of any records pertaining to the driver’s use of alcohol or controlled substances, including any records pertaining to his or her alcohol or controlled substances tests. An employer that receives such a written request shall promptly provide the records requested by the driver. The Drug and Alcohol Records Request is provided for drivers who wish to request their drug and/or alcohol records. (Form No. 847-jFS-C3) NOTE: the Drug and Alcohol Records Request is not required for DOT compliance. 2.

3. ALCOHOL AND DRUG EMPLOYEE’S CERTIFIED RECEIPT: (382.601(d)) Each employer shall ensure that each driver is required to sign a statement certifying that he or she has received a copy of the materials described in Section 382.601. Each employer shall maintain the original of the signed certificate and may provide a copy of the certificate to the driver. (Form No. 872-FS-C2). ALCOHOL AND/OR CONTROLLED SUBSTANCE TEST NOTIFICATION: (382.113) Before performing each alcohol or controlled substances test under Part 382, each employer shall notify the driver that the alcohol or controlled substances test is required by Part 382. No employer shall falsely represent that a test is administered under Part 382. (Form No. 375-FSC2) NOTE: The Alcohol and/or Controlled Substance Test Notification is not required for DOT compliance.

4.

DRIVER INVESTIGATION HISTORY RECORDS: 1. SAFETY PERFORMANCE HISTORY RECORDS REQUEST: (40.25)(391.23) Each motor carrier must investigate each driver’s safety performance history with each of the driver’s DOTregulated employers during the preceding three years. The investigation may consist of personal interviews, telephone interviews, letters, or any other method for investigating that the carrier deems appropriate. A written record must be kept with respect to each previous employer contacted, or good faith efforts to do so, and must include the previous employer’s name and address, date of contact or the attempts made, and the information received about the driver 2. DRUG TEST RESULTS: (40.163) the medical review officer (MRO) is required to report all drug test results to the employer. The report must contain the information listed in Section 40.163©. The report may be forwarded to the employer by a consortium/third party administrator (C/TPA) acting as an intermediary. (Form No. 873-FS-C4). 3.

OBSERVED BEHAVIOR REASONABLE SUSPICION RECORD: (382.307) A written record shall be made of the observation leading to an alcohol or controlled substances reasonable suspicion test, and signed by the supervisor or company official who made the observations, within 24 hours of the observed behavior or before the results of the alcohol or controlled substances test are released, whichever is earlier. (Form No. 862-FS-C#). 4. U.S. DOT ALCOHOL TESTING FORM: (a40.225) the DOT alcohol Testing form (ATF) must be used for every DOT alcohol test beginning February1, 2002. The ATF must be a threepart carbonless manifold form. Motor carriers are not permitted to modify or revise the ATF except as allowed in Section 40.225. (Form No. 570FS-C3 or 476-FS-C3) 5. FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM:

(40.45) The Federal Drug Testing Custody and Control Form (CCF) must be used to document every urine collection required by the DOT drug testing program. The CCF must be a five-part carbonless manifold form. You must not use a non-Federal form or an expired Federal form to conduct a DOT urine collection. Motor carriers are not permitted to modify or revise the CCF except as allowed in Section 40.45. (form no. 472-FC-C5) 2. PREVIOUS EMPLOYEE SAFETY PERFORMANCE HISTORY: (391.23) Each motor carrier must investigate each driver’s safety performance history with each of the driver’s DOT-regulated employers during the preceding three years. The Previous Employee Safety Performance History form allows a driver’s previous employer to document the driver’s safety performance history upon termination of prospective employer(s) upon request. The information must be forwarded within 30 days of the request. Previous employers must keep a record of each request and the response for one year, including the date, the party to whom it was released, and a summary identifying what was provided. The information on this form must be kept on file until three years after termination date. (Form No. 854-F) NOTE: The Previous Employee Safety Performance History is not required for DOT compliance.

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PREVIOUS PRE-EMPLOYMENT EMPLOYEE ALCOHOL AND DRUG TEST STATEMENT Sec. 40.25(j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she had a positive test or a refusal to test, you must not use the employee to perform safety-sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))

Prospective Employee Name:____________________________ ID Number:_______________________ (print) The prospective employee is required by Sec. 40.25(j) to respond to the following questions. (1)

Have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safetysensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years? Check one:

(2)


Yes
No

If you answered yes, can you provide/obtain proof that you’ve successfully completed the DOT return-to-duty requirements? Check one:


Yes
No

I certify that the information provided on this document is true and correct. Prospective Employee Signature: ________________________________ Date: ____________________ Witnessed By: _____________________________ Date: ____________________ (signature)

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ALCOHOL & DRUG RECORDKEEPING LOG Pre-employment Documents Previous employer information Requested from __________________________ __________________________ _____________________ _____________________

Date Requested ______________ ______________ ______________ ______________

Date Rec’d Reviewed By ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________

Retain Until ____________ ____________ ____________ ____________

Comments: ________________________________________________________________________________________________ _________________________________________________________________________________________________________ Drug and alcohol records Requested from ___________________________ ___________________________ ___________________________ ___________________________

Date Requested ______________ ______________ ______________ ______________

Date Rec’d ___________ ___________ ___________ ___________

Reviewed By ___________________ ___________________ ___________________ ___________________

Retain Until _________ __________ __________ ___________

Comments: _________________________________________________________________________________________________ _________________________________________________________________________________________________________ Employee’s alcohol and drug statement regarding pre-employment tests:

_____________________

Employee’s signed receipt for drug/alcohol educational materials:

_____________________

(date completed) (date completed)

The company intends to use the exception to pre-employment drug testing contained in Sec. 382.301:
Yes
No If yes, the company has retained the following documents to satisfy Sec. 382.301:____________________________________________________________________________________________________ _______________________________________________________________________________________________________ The company has found this employee has, within the last three years, violated part 382:
Yes
No If yes, the company has retained the following documents regarding the employee’s completion of the return-to-duty process: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Instructions for completing Alcohol and Drug Test documentation on reverse side 1. 2.

3.

Record type of test (pre-employment, random, reasonable suspicion, etc.), date test was conducted, and date results were received. Document the records being retained related to each test. These would include, but are not limited to: Federal Drug Testing Custody and Control Form (CCF), U.S. Department of Transportation Alcohol Testing Form (ATF), Medical Review Officer (MRO) reports; driver evaluations and referrals; documents related to reasonable suspicion; documents regarding decisions on post-accident tests; documents related to a driver’s refusal to test; and documents presented by a driver to dispute the results of an alcohol/drug test. Refer to requirements in Section 382.401 and Section 40.333 for complete retention requirements. Record the date in the “Retain Until” portion of the form.

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Alcohol Tests Type of Test

Test Date

Date Results Rec’d

Record to be Retained Until

1. ___________ _______ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 2. __________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 3. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 4. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ * Retain for 1 year minimum – Alcohol test results with a concentration of less than 0.02. * Retain for 5 years minimum – Alcohol test results with results of 0.02. or greater. Drug Tests 1. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 2. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 3. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 4. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________

5. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ 6. ___________________ ______________ ______________________ _________________________ Records related to this test: __________________________________________________________________________________ ________________________________________________________________________________________________________ ** Retain for minimum of 1 year – Records of negative and cancelled substance test results. ** Retain for minimum of 5 years – Driver verified positive controlled substance test results. This file contains the following documents related to SAP reports and the return-to-duty process: __________________________ ________________________________________________________________________________________________________ This file contains the following documents on the inability to provide sufficient breath or urine for testing: ________________________________________________________________________________________________________ This file contains the following records related to other violations of part 382: _________________________________________ ________________________________________________________________________________________________________

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No comment: employers who do not respond to Safety Performance History inquires If you’re a responsible carrier who is diligent in sending out the Safety Performance History background investigation in accordance with §391.23, what do you do if a former-DOT regulated employer ignores or just plain refuses to respond to your inquiry? Can the previous employer withhold information pending payment of an administrative fee to its own organization or its third-party administer? These are just a few of the many questions that the transportation industry is concerned with since the implementation of the revisions to §391.23 (applicable to those individuals hired or transferring into a driving position after October 29, 2004). The clock is ticking The former employer only has 30 days after receiving the request of Safety Performance History data to respond under §391.23(g)(1). If a former DOT-regulated employer does not respond within the confines of this deadline, it is a violation of the FMCSRs. The requesting party can lodge a complaint in accordance with §386.12 (see below). Required information Carriers are also concerned with former DOT-regulated employers who do not answer all of the questions posed to them. Many are left wondering if they have grounds to start the complaint process. The answer: it depends. There are three categories of information that have to be requested from previous employers. They are: •

• •

General identification and employment information — This includes basic identifying data about the driver and basic employment information, including starting and ending dates and job responsibilities. Accident information — This includes the applicant's three-year accident history, as recorded on the previous employer's accident register. Drug/alcohol testing information — This must be requested of employers for whom the applicant was subject to DOT-required drug/alcohol testing, even if the applicant will not be subject to such testing for the prospective employer. This includes whether or not the applicant ever failed a drug/alcohol test or failed to complete rehabilitation. The previous employer must receive a written release from the driver before providing these records.

If the prospective employer asks anything outside of the scope of these questions, such as subjective information (i.e., quality of work, character, reason for termination, etc.) or information on non-DOT recordable accidents, the former employer is not obligated to address these areas. A carrier is only protected from potential liability if it answers the DOT-required 31

questions. (See: §391.23(l)(1)-(l)(2)) Offering information outside of this often is against company policy. In addition, if the requesting carrier does not include a specific written consent signed by the driver for DOT drug and alcohol test information, the former employer’s hands are tied in regard to answering – they cannot. Examples could include a document sent without the consent, or a request with a “blanket release” for information which is unacceptable under the DOT. The former employer should consider contacting the requesting party to obtain the proper signed release, because if they sit on the request too long, they may be accused of not releasing information within the required 30 days. If everything sent to a former DOT-regulated employer meets DOT requirements, they must respond within 30 days, even if there is no Safety Performance History occurring within the past three years to report. They must still send a statement to that effect. The former employer or its service providers also cannot make release of information contingent upon receipt of a fee. Complaint process The FMSCA takes non-compliance with §391.23 by a former DOT-regulated employer very seriously. Section 391.23(c)(4) directs a carrier to §386.12, the complaint process. However, this portion of the regulations does not give a phone number or address to pursue the process. To file a complaint, carriers are encouraged to use of the FMCSA safety violation and commercial complaint hotline (1(888) DOT-SAFT) or the website (http://www.1-888-dotsaft.com), as indicated in the Preamble to the final rule, Safety Performance History of New Drivers.

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DRIVER RECORD CARD NAME_________________________________________ (LAST)

(FIRST)

ADDRESS______________________________________ (NUMBER)

DATE OF BIRTH____________________ SEX______

(M)

DATE HIRED___________TERMINATED_________

(STREET)

_________________________________________

REASON FOR TERMINATION__________________

(PO BOX)

(ZIPCODE)

_______________________________________________________

PHONE NO.______________ SSN___________________

COMPANY NO._________LOCATION____________

(CITY)

(STATE)

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY: NAME_________________________________________

PHONE NO.___________________________________

ADDRESS_____________________________________

RELATIONSHIP_______________________________

LICENSE RECORD State & Hazmat Class Y N

Number

Renewal Dates

Date

Location

ACCIDENTS No. of Injuries

No. of Fatalities

Hazmat Spill

Hazardous Material Endorsement Y - Yes N - No DRUG & ALCOHOL

Date of Positive Test

RECORD OF POSITIVE TEST

SAP PROCESS COMPLETE Yes No

RETURN TO WORK Yes

No

PHYSICAL EXAMINATION RECORD DATE

DOCTOR

QUALIFIED

CONDITION

NOT QUALIFIED RECORD OF COMMENDATIONS, COMPLAINTS, VIOLATIONS DATE

CONDITION W/H.A. – With hearing Aid Diabetic – OK by W/C.L. – With Corrective Lenses Operation of 49CFR 391.64 SAFETY AWARD RECORD Qualification Date: _______________________________________________ FROM TO AWARD FROM TO AWARD

NATURE

SOURCE

ACTION TAKEN

REMARKS: _______________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 33

CHECKLIST FOR QUALIFICATION OF NEW DRIVERS NAME OF DRIVER: _______________________________ SOCIAL SECURITY NO: __________________________ ADDRESS: ______________________________________________________________________________________ (Number and Street) (City) (State) (Zip Code) INSTRUCTIONS TO CARRIER: The following checklist is intended to help the motor carrier obtain all of the documents required by the Federal Motor Carrier Safety Regulations. Record the information to acknowledge receipt of the documents. Alcohol and controlled substance and safety performance history information must be maintained in a confidential file. Date of Request Forwarded

Date Document Returned

Document Approved Date

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

Signature

1. Application for Employment ___________ 2. Fair Credit Reporting Act Disclosure Statement ___________ 3. Request for Check of Driving Record (List state agencies written to) ____________________________ ___________ ____________________________ ___________ 4. Medical Examiner’s Certificate ___________ NOTE: Medical Examination Report form should be maintained in a confidential file ___________

5. Record and Certificate of Road Test _____________ _____________ __________ ___________ 6. Certificate of Compliance _____________ _____________ __________ ___________ 7. Driver’s Statement of On-duty Hours _____________ _____________ __________ ___________ 8. Entry-Level Driver Training Certificate _____________ _____________ __________ ___________ 9. Longer Combination Vehicles Driver Certification _____________ _____________ __________ ___________ OTHER DOCUMENTS 10. ___________________________ _____________ _____________ __________ ___________ 11. ___________________________ _____________ _____________ __________ ___________ ALCOHOL AND CONTROLLED SUBSTANCES TESTING (NOTE: THESE DOCUMENTS MUST BE MAINTAINED IN A SECURE LOCATION WITH CONTORLLED ACCESS) 1. Inquires to previous employers (past 3 years) for part 382 drug and alcohol test information _____________ _____________ __________ ___________ 2. Pre-employment test-controlled substances (employers copy of Chain of Custody Form and Test 34

3.

4.

5. 6.

Test Result) ___________ Certificate of receipt–company drug and alcohol policy ___________ Previous Pre-Employment Employee Alcohol and Drug Statement ___________ OTHER DOCUMENTS __________________________ ___________ __________________________ ___________

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

_____________

_____________

__________

SAFETY PERFORMANCE HISTORY (NOTE: THESE DOCUMENTS MUST BE MAINTAINED IN A SECURE LOCATION WITH CONTROLLED ACCESS)

1. Request for Information From Previous Employer __________________________ _____________ ___________ __________________________ _____________ ___________ __________________________ _____________ ___________ 2. Previous Employee Safety Performance History __________________________ _____________ __________ OTHER DOCUMENTS 3. ________________________ _____________ ______________________

_____________

__________

_____________

__________

_____________

__________

_____________

__________

_____________

DOT DFWP Previous Employer -Applicant Verification Form To comply with CFR 49 Part 383 we must contact previous employers of applicant drivers to verify compliance of the applicant with the former employers Drug Free Workplace Program. This form must be completed and reviewed prior to the applicant driving a commercial vehicle for us. This completed form will be kept as part of the application for employment. Applicant to verify: _______________________Verifier Name: _________________ Dates worked at last employer: (start) _________________(end)_________________ Name of Prior or Current Employer: _______________________________________ Address: _____________________________________________________________ Phone #: _________________________ or E-mail:____________________________

35

Name of Drug Program Administrator questioned:______________________________ Questions to be answered by former/current employer Drug Program Administrator: 1) Did the driver stated above participate in the DOT- DFWP Program? ________ 2) Does the program conform with the DOT DFWP CFR 49 Part 40? __________ 3) Any reason that the applicant is not in good standing of this program? ________ 4) Has this applicant ever refused a drug screen under this program? __________ 5) What was the last test date for this driver for alcohol or drugs?_____________ 6) What was the result of a drug test administered in the last 6 months? _________ 7) Has there been any violations of the alcohol misuse or drug use rules? ________ Additional Comments: ___________________________________________________ ______________________________________________________________________ ______________________________________________________________________

DRUG AND ALCOHOL RECORDS REQUEST This request is being made in compliance with the Department of Transportation regulations, §40.329, §40.331(a) and §382.405(b) and (f). See the regulations on the second page of this form.

STEP 1: TO BE COMPLETED BY THE EMPLOYEE INFORMATION REQUESTED FROM:
Previous employer
Laboratory
Medical review officer
Substance abuse professional
Other ________ Name: ___________________________________________________________________________________ (Print)

Street: ___________________________________________________________________________________

36

City, State, Zip Code: ____________________________________________ Telephone No. ________________ INFORMATION REQUESTED BY Employee Name: _________________________________________Social Security/I.D. No. ___________________ (Print)

Street: ___________________________________________________________________________________ _ City, State, Zip Code: ____________________________________________ Telephone No. ________________ I am submitting this written request to obtain copies of my Department of Transportation drug and/or alcohol testing records in your possession. Specifically, I request that you send the following records: __________________________________________________________________________________________ ____ __________________________________________________________________________________________ ____ __________________________________________________________________________________________ ____ __________________________________________________________________________________________ ___

This information should be:


Sent to me at the address above
Sent to the following individual/company

Name: __________________________________________________________________________________ Company:___________________________________________________________________________ _ Street: ___________________________________________________________________________________ City, State, Zip Code: ____________________________________________ Telephone No._____________ _____________________________________ Employee Signature

Date:_______/__________/________ Month Day Year

STEP 2: TO BE COMPLETED BY THE EMPLOYER/SERVICE AGENT 37

Copies of the drug and/or alcohol testing records have been supplied to the following person as authorized by the above named employee: Name: ______________________________ __________________________

*

* Street: _______________________________ * ____________________________________ * City, State, Zip Code: ___________________ *

Comments:

______________________________

_______________________________________ Telephone No. ______________ Release Date: ____/____/____ Signature of Person Providing Information

§40.329 What information must laboratories, MROs, and other service agents release to employees? (a) As an MRO or service agent you must provide, within 10 business days of receiving a written request from an employee, copies of any records pertaining to the employee’s use of alcohol and/or drugs, including records of the employee’s DOT-mandated drug and/or alcohol tests. You may charge no more than the cost of preparation and reproduction for copies of these records. (b) As a laboratory, you must provide, within 10 business days of receiving a written request from an employee, and made through the MRO, the records relating to the results of the employee’s drug test (i.e., laboratory report and data package). You may charge no more than the cost of preparation and reproduction for copies of these records. (c) As a SAP, you must make available to an employee, on request, a copy of all SAP reports (see §40.311). §40.311 To what additional parties must employers and service agents release information? As en employer or service agent you must release information under the following circumstances: (a) If you receive a specific, written consent from and employee authorizing the release of information about that employee’s drug or alcohol tests to an identified person, you must provide the information tot eh identified person. For example, as an employer, when you receive a written request from a former employee to provide information to a subsequent employer, you must do so. In providing the information, you must comply with the terms of the employee’s consent. §382.405(b) A driver is entitled, upon written request, to obtain copies of any records pertaining to the driver’s use of alcohol or controlled substances, including any records pertaining to his or her alcohol or controlled substances tests. The employer shall promptly provide the records requested by the driver. Access to a driver’s records shall not be contingent upon payment for records other than those specifically requested. § 382.405(f) Records shall be made available to a subsequent employer upon receipt of a written request from a driver. Disclosure by the subsequent employer is permitted only as expressly authorized by the terms of the driver’s request.

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