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Motor Carrier Forms and Information

Revised October 2018

For more information:

Illinois Department of Transportation

Commercial Vehicle Safety Section

2300 S. Dirksen Parkway, Room 323

Springfield, IL 62764

217/785-1181

FAX 217/782-9159

TTY 217/524-4875

Motor Carrier Forms and Information

Table of Contents

Revised October 2018 Page(s)

❖ Motor Carrier Forms and Information Websites 1-2

❖ Help, I Need an Answer – Phone Numbers 3

❖ Accident Register 5

❖ Insurance Endorsements 7-9

❖ Requirements for Driver’s Qualification File 11

❖ Driver Qualification File Checklist 12

❖ Application for Employment 13-14

❖ Safety Performance History Records Request 15-17

❖ Inquiry to Agency for Driver’s Record 19

❖ Driver’s Road Test Examination 21

❖ Certificate of Driver’s Road Test 23

❖ Medical Examination Report and Certificate 25-35

❖ Illinois SOS Driving Record Abstract Request Form 37-38

❖ Motor Vehicle Driver’s Certification of Violators 39

❖ Annual Review of Driving Record 41

❖ Driver’s Time Record 43

❖ Driver’s Time Record – Operations Within 100 Mile Radius 45

❖ Driver’s Time Record – Operations Within 150 Mile Radius 47

❖ Hours-of-Service Record For First Time or Intermittent Drivers 49

❖ Driver’s Vehicle Inspection Report 51

❖ Inspection, Repair and Maintenance Record 53

❖ Vehicle Service Due Status Report 55

❖ Annual Vehicle Inspection Report 57

❖ North American Standard Inspection Procedure 59-60

❖ Inspector Qualifications 61

❖ Brake Inspector Qualifications 63

❖ Letter of Off-Duty Authorization 65

❖ Driver’s List - Worksheet Examples 67

❖ Vehicle List - Worksheet Examples 68

(MCS-90)

(Driver's Daily Log)

MOTOR CARRIER FORMS AND INFORMATION Revised September 2012

1. Help, I Need an Answera) A Motor Carrier's Guide to Improving Highway Safety

http://www.fmcsa.dot.gov/safety-security/eta/ETA%20Final%20508c.pdf The above is a 13.5mb download - could take a while!

b) Exempt Commodities List (Administrative Ruling 119)http://www.fmcsa.dot.gov/documents/adminrule.pdf

c) International Fuel Tax Agreement (IFTA)http://www.revenue.state.il.us/taxforms/Misc/MFT/MFUT-12.pdf

d) Illinois Commerce Commission (ICC) - Unified Carrier Registration (UCR)http://www.icc.illinois.gov/motorcarrier/ucr.aspx

2. Accident Registerhttp://www.fmcsa.dot.gov/documents/forms/form 1.pdf (without column for tow-a-ways) http://www.fmcsa.dot.gov/documents/eta/part390form1.pdf (with column for tow-a-ways)

3. Driver Qualificationa) Application for Employment

http://www.fmcsa.dot.gov/documents/forms/application.pdf

b) Request/Inquiry for Information from Previous Employerhttp://www.fmcsa.dot.gov/documents/forms/reguestforinfo.pdf

c) Inquiry to Agency for Driver's Recordhttp://www.fmcsa.dot.gov/documents/forms/inguirystateagency.pdf (all other states)

d) Annual Review of Driving Recordhttp://www.fmcsa.dot.gov/documents/forms/annualreview.pdf

e) Annual Motor Vehicle Driver's Certification of Violationshttp://www.fmcsa.dot.gov/documents/forms/drcertviolat.pdf

f) Certificate of Driver's Road Testhttp://www. f mesa .dot.gov/documents/ eta/ certd riverrdtestnew. pdf

g) Driver's Road Test Examinationhttp://www.fmcsa.dot.gov/documents/eta/drrdtestexam3.pdf

h) Medical Examination Report and Certificatehttp://www. fmcsa .dot.gov/ docu ments/forms/649f. pdf (report)

http://www.fmcsa.dot.gov/documents/forms/651FSL2. pdf ( certificate)

4. Hours of Servicehttp://www.fmcsa.dot.gov/rules-regulations/truck/driver/hos/fmcsa-guide-to-hos.pdf

a) Driver's Time Record Form for operations within a 100-150 mile radiushttp://dps.alabama.gov/Documents/Forms/MotorCarrier-13-DriversTimeRecord100Mi.pdf

b) Hours-of-Service Record for First Time or Intermittent Drivershttp://www.wsp.wa.gov/traveler/docs/cvd/395 form2.pdf

c) Driver's Daily Loghttp://www. fmcsa .dot.gov/documents/ eta/logpage. pdf

d) Summary of Hours Worked and Hours Availablehttp://www.fmcsa.dot.gov/documents/forms/part 395summaryhrs.pdf

Page 1

e) Log Book Exampleshttp://www.fmcsa.dot.gov/rules-regulations/topics/hos/hos-logbo ok-examples.htm

5. Insurance Endorsementshttp://www.fmcsa.dot.gov/documents/eta/part-387.pdf

6. Controlled Substances and Alcohol Testing

a) Alcohol and Drug Ruleshttp://www. fmcsa .dot .gov I ru les-regu I ations/topics/ drug/ engtesti ng. htm

b) Alcohol Testing Formhttp://www. fm csa .dot.gov/ docu ments/fo rms/testform. pdf

c) Collection Formhttp://www.fmcsa.dot.gov/documents/forms/new mis form.pdf

7. Maintenance

a) Annual Vehicle Inspection Reporthttp://www.fmcsa.dot.gov/documents/eta/part-396form6.pdf

b) Driver's Vehicle Inspection Reporthttp://www.fmcsa.dot.gov I documents/ eta/sec396-form 1-1. pdf

c) Vehicle Service Status Due Reporthttp://www.fmcsa.dot.gov/ documents/ eta/sec396-form2-l.pdf

d) North American Standard Inspection Procedurehttp://www.fmcsa.dot.gov/documents/eta/sec396-form3-l.pdf

e) Inspection Levelshttp://www.fmcsa.dot.gov/safety-security/safety-initiatives/mcsap/insplevels.htm

f) Inspection, Repair and Maintenance Recordhttp://www.fmcsa.dot.gov/documents/eta/sec396-form5-l.pdf

g) Inspector Qualificationshttp://www.fmcsa.dot.gov/ documents/ eta/sec396-form 7-1.pdf

h) Brake Inspector Qualificationshttp://www.fmcsa.dot.gov/ documents/ eta/sec396-form8-l. pdf

i) Bus Emergency Exits Inspectionhttp://www.wutc.wa.gov/webimage.nsf/web+objects/Safety+Guide/$file/busexit.pdf

j) Bus Safety Inspection Checklisthttp://gacc.nifc.gov/wgbc/logistics/equipment supplies/2008 bus inspection.pdf

k) On Guard (How to Adjust your Brakes)http://www. wsp. wa.gov /traveler/ docs/ cvd/396 form 10.pdf

8. Hazardous Materials Forms: (http://www.tmcsa.dot.gov/torms/print/hazmat.html

a) Hazardous Materials Incident Report(http://www.phmsa.dot.gov/hazmat/incident-report)

Follow instruction at the website

b) · Hazardous Materials Registration Statement(http://www.fmcsa.dot.gov/documents/forms/regform2002l.pdf) (Page 1)

(http://www.fmcsa.dot.gov/documents/forms/regform20022.pdf) (Page 2)

Page 2

Division of Transportation Safety

Answers to Your Questions IDOT • DIVISION OF TRANSPORTATION SAFETY • COMMERCIAL VEHICLE SAFETY SECTION

HELP, I NEED AN ANSWER! (Revised December 2014)

United States Department of Transportation –

Federal Motor Carrier Safety Administration (FMCSA)

Registration requirements for interstate carriers 217-492-4608

Federal Census (US DOT) Number requirements 217-492-4608

Federal Motor Carrier Safety Regulations 217-492-4608

FMCSA Hotline 1-888-368-7238

Motor Carrier Identification Report (Form MCS-150) 1-800-832-5660

The following are agencies within the State of Illinois:

Department of Transportation

Road condition/construction 1-800-452-4368

Oversize/Overweight Vehicle Permits 217-785-1477

Vehicle Inspection Requirements 217-785-1181

Diesel Emission Inspection Requirements 217-557-4613

Illinois Hazardous Materials Transportation Regulations 217-785-1181

Illinois Motor Carrier Safety Regulations 217-785-1181

School Bus Regulations 217-785-1181

State Police

Enforcement of Illinois Hazardous Materials Transportation Regulations 217-782-6267

Enforcement of Illinois Motor Carrier Safety Regulations 217-782-6267

Enforcement of Second Division Vehicle Regulations 217-782-6267

Secretary of State

Commercial Driver’s License (CDL) Help Line 217-524-1350

Driving Record Requests 217-782-2720

International Registration Plan (IRP) 217-785-1800

Department of Revenue

Motor Fuel Tax Permit & Decals 217-785-1397

Environmental Protection Agency

Vehicle Emission Testing (Gasoline) 217-785-7449

Commerce Commission

Unified Carrier Registration (UCR) 217-782-4654

Registration Requirements for Intrastate Carriers 217-782-4654

Hazardous Materials Forms: www.hazmat.dot.gov

Federal Motor Carrier Safety Administration Website: www.fmcsa.dot.gov

Illinois Department of Transportation Motor Carrier Safety and Hazardous Materials Transportation

Regulations: www.ilga.gov/commission/jcar/admincode/092/092parts.html

Page 3

http://www.hazmat.dot.gov/

http://www.fmcsa.dot.gov/

http://www.ilga.gov/commission/jcar/admincode/092/092parts.html

ACCIDENT REGISTERIndex Number

Date Location City/State

Driver Name

Number Injuries

Number Fatals

Vehicles Towed

HM Incident

NOTE: This form is provided as a suggested format for recording accidents. A motor carrier may use any register format for documenting recordable accidents, per Part 390.

Page 5

FORM MCS-90 Revised 01/05/2017 OMB No.: 2126-0008 Expiration: 01/31/2020

FORM MCS-90 Page 1 of 3

United States Department of TransportationFederal Motor Carrier Safety Administration

A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0008. Public reporting for this collection of information is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, Washington, D.C. 20590.

Endorsement for Motor Carrier Policies of Insurance for Public Liabilityunder Sections 29 and 30 of the Motor Carrier Act of 1980

FORM MCS-90

(continued on next page)

Issued to

Name of Insurance Company:

Countersigned by:

Dated at

Amending Policy Number: Effective Date:

on this ,day of

of

(Motor Carrier name) (Motor Carrier state or province)

(authorized company representative)

The policy to which this endorsement is attached provides primary or excess insurance, as indicated for the limits shown (check only one):

Whenever required by the Federal Motor Carrier Safety Administration (FMCSA), the company agrees to furnish the FMCSA a duplicate of said policy and all its endorsements. The company also agrees, upon telephone request by an authorized representative of the FMCSA , to verify that the policy is in force as of a particular date. The telephone number to call is: .

Cancellation of this endorsement may be effected by the company of the insured by giving (1) thirty-five (35) days notice in writing to the other party (said 35 days notice to commence from the date the notice is mailed, proof of mailing shall be sufficient proof of notice), and (2) if the insured is subject to the FMCSA’s registration requirements under 49 U.S.C. 13901, by providing thirty (30) days notice to the FMCSA (said 30 days notice to commence from the date the notice is received by the FMCSA at its office in Washington, DC).

This insurance is primary and the company shall not be liable for amounts in excess of $ for each accident.

This insurance is excess and the company shall not be liable for amounts in excess of $ for each accident in excess of the underlying limit of $ for each accident.

Date Received:USDOT Number:

Page 7



The insurance policy to which this endorsement is attached provides automobile liability insurance and is amended to assure compliance by the insured, within the limits stated herein, as a motor carrier of property, with Sections 29 and 30 of the Motor Carrier Act of 1980 and the rules and regulations of the Federal Motor Carrier Safety Administration (FMCSA).

In consideration of the premium stated in the policy to which this endorsement is attached, the insurer (the company) agrees to pay, within the limits of liability described herein, any final judgment recovered against the insured for public liability resulting from negligence in the operation, maintenance or use of motor vehicles subject to the financial responsibility requirements of Sections 29 and 30 of the Motor Carrier Act of 1980 regardless of whether or not each motor vehicle is specifically described in the policy and whether or not such negligence occurs on any route or in any territory authorized to be served by the insured or elsewhere. Such insurance as is afforded, for public liability, does not apply to injury to or death of the insured’s employees while engaged in the course of their employment, or property transported by the insured, designated as cargo. It is understood and agreed that no condition, provision, stipulation, or limitation contained in the policy, this endorsement, or any other endorsement thereon,

or violation thereof, shall relieve the company from liability or from the payment of any final judgment, within the limits of liability herein described, irrespective of the financial condition, insolvency or bankruptcy of the insured. However, all terms, conditions, and limitations in the policy to which the endorsement is attached shall remain in full force and effect as binding between the insured and the company. The insured agrees to reimburse the company for any payment made by the company on account of any accident, claim, or suit involving a breach of the terms of the policy, and for any payment that the company would not have been obligated to make under the provisions of the policy except for the agreement contained in this endorsement.

It is further understood and agreed that, upon failure of the company to pay any final judgment recovered against the insured as provided herein, the judgment creditor may maintain an action in any court of competent jurisdiction against the company to compel such payment.

The limits of the company’s liability for the amounts prescribed in this endorsement apply separately to each accident and any payment under the policy because of anyone accident shall not operate to reduce the liability of the company for the payment of final judgments resulting from any other accident.

DEFINITIONS AS USED IN THIS ENDORSEMENT

Accident includes continuous or repeated exposure to conditions or which results in bodily injury, property damage, or environmental damage which the insured neither expected nor intended.

Motor Vehicle means a land vehicle, machine, truck, tractor, trailer, or semitrailer propelled or drawn by mechanical power and used on a highway for transporting property, or any combination thereof.

Bodily Injury means injury to the body, sickness, or disease to any person, including death resulting from any of these.

Property Damage means damage to or loss of use of tangible property.

Environmental Restoration means restitution for the loss, damage, or destruction of natural resources arising out of the accidental discharge, dispersal, release or escape into or upon the land, atmosphere, watercourse, or body of water, of any commodity transported by a motor carrier. This shall include the cost of removal and the cost of necessary measures taken to minimize or mitigate damage to human health, the natural environment, fish, shellfish, and wildlife.

Public Liability means liability for bodily injury, property damage, and environmental restoration.

(continued on next page)

Page 8



SCHEDULE OF LIMITS — PUBLIC LIABILITY

Type of carriage Commodity transported January 1, 1985

(1) For-hire (in interstate or foreign commerce, with a gross vehicle weight rating of 10,000 or more pounds).

Property (nonhazardous) $750,000

(2) For-hire and Private (in interstate, foreign, or intrastate commerce, with a gross vehicle weight rating of 10,000 or more pounds).

Hazardous substances, as defined in 49 CFR 171.8, transported in cargo tanks, portable tanks, or hopper-type vehicles with capacities in excess of 3,500 water gallons; or in bulk Division 1.1, 1.2, and 1.3 materials, Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material; in bulk Division 2.1 or 2.2; or highway route controlled quantities of a Class 7 material, as defined in 49 CFR 173.403.

$5,000,000

(3) For-hire and Private (in interstate or foreign commerce, in any quantity; or in intrastate commerce, in bulk only; with a gross vehicle weight rating of 10,000 or more pounds).

Oil listed in 49 CFR 172.101; hazardous waste, hazardous materials, and hazardous substances defined in 49 CFR 171.8 and listed in 49 CFR 172.101, but not mentioned in (2) above or (4) below.

$1,000,000

(4) For-hire and Private (In interstate or foreign commerce, with a gross vehicle weight rating of less than 10,000 pounds).

Any quantity of Division 1.1, 1.2, or 1.3 material; any quantity of a Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined in 49 CFR 173.403.

$5,000,000

* The schedule of limits shown does not provide coverage. The limits shown in the schedule are for information purposes only.

n

Page 9

REQUIREMENTS FOR DRIVER'S QUALIFICATION FILE (49 CFR 391.Sl(a))

Items That Must be Kept in Driver's File

1. DRIVER'S application for employment (see specifics of DOTapplication)

2. Previous Employer Requirements:• Information from any previous or current employer that

applicant was employed as a driver (past 10 years)• Information from any previous or current employer even if

not employed as a driver (past 3 years)• Information from any previous or current employer that had

an alcohol and/or drug testing program (49 CFR 391 .23(e))3. Hours of Service (7 previous days if needed)4. Pre-employment alcohol/drug test and negative results5. Initial Motor Vehicle Report from State Entity (valid)

Items That Must be Reviewed/Updated Annually

6. Driver's Road Test Examination and Certificate of Road Test <or>sCopy of Driver's current CDL (keep current and previous one)

. 7. Driver's Medical Certificate (good for a maximum period of two years - keep current and previous one)

8. Copy of Waiver (if applicable and granted by USDOT)

If Driver Works For Employer More Than 1 Year {365 days) (Prior to employee's anniversary of employment date and every year thereafter)

9. ANNUAL printed driving record check from State (Motor VehicleReport)

10. ANNUAL driver declaration of violations11. ANNUAL motor carrier review of driving record

Page 11

DRIVER QUALIFICATION FILE CHECKLIST

❏ Driver’s Application For Employment(49 CFR 391.21)

❏ Inquiry To Previous Employers – 3 Years(49 CFR 391.23(A) (2) & (C))

❏ Inquiry To State Agencies – 3 Years(49 CFR 391.23(A) (1) & (B))

Inquiry To State Agencies – Annual(49 CFR 391.25(A) & (C))

❏ Annual Review Of Driving Record(49 CFR 391.25)

❏ Annual Driver’s Certification Of Violations(49 CFR 391.27)

❏ Driver’s Road Test Certificate or Equivalent*(49 CFR 391.31)

❏ Medical Examiner’s Certificate*(49 CFR 391.43)

❏ Multiple-Employer Drivers(49 CFR 391.63)

*NOTE: DRIVERS MUST BE ISSUED COPIES OF THESE CERTIFICATES.DRIVERS NEED ONLY HAVE A COPY OF THE MEDICAL EXAMINER’S CERTIFICATE IN THEIR POSSESSION WHILE DRIVING

Page 12

APPLICATION FOR EMPLOYMENT COMPANY __________________________________ STREET ADDRESS ____________________________________

CITY, STATE AND ZIP CODE _________________________________________________________________________

NAME ___________________________________________________________________________________________ (FIRST) (MIDDLE) (Maiden Name, if any) (LAST)

ADDRESS __________________________________________________________________ HOW LONG? _________ (STREET) (CITY) (STATE & ZIP CODE)

DATE OF BIRTH ________________ SOCIAL SECURITY NO. _______________________ HIRE DATE __________

TELEPHONE NUMBER ______________________________ E-MAIL ADDRESS _______________________________

PREVIOUS THREE YEARS RESIDENCY __________________________________________________________________________________ # YEARS ______ (STREET) (CITY) (STATE & ZIP CODE)

__________________________________________________________________________________ # YEARS ______ (STREET) (CITY) (STATE & ZIP CODE)

__________________________________________________________________________________ # YEARS ______ (STREET) (CITY) (STATE & ZIP CODE)

(ATTACH SHEET IF MORE SPACE IS NEEDED) LICENSE INFORMATION

Section 383.21 FMCSR states “No person who operates a commercial motor vehicle shall at any time have more than one river’s license”. I certify that I do not have more than one motor vehicle license, the information for which is listed below.d

STATE LICENSE NO. TYPE EXPIRATION DATE

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.)

DATES FROM TO

APPROX. NO. OF MILES (TOTAL)

STRAIGHT TRUCK

TRACTOR AND SEMI-TRAILER

TRACTOR - TWO TRAILERS

OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SH ET IF MORE SPACE IS NEEDED) E

DATES NATURE OF ACCIDENT (HEAD-ON, REAR-END, UPSET, ETC.)

NUMBERFATALITIES

NUMBERINJURIES

CHEMICALSPILLS

YES NO

YES NO

YES NO

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS)

DATE CONVICTED (month/year)

VIOLATION STATE OF VIOLATION LOCATION

PENALTY (forfeited bond, collateral and/or points)

(ATTACH SHEET IF MO E SPACE IS NEEDED) R

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES _____ NO _____

If yes, explain ______________________________________________________________________________________

B. Has any license, permit or privilege ever been suspended or revoked? YES _____ NO _____

If yes, explain ______________________________________________________________________________________

Page 13

EMPLOYMENT RECORD(ATTACH SHEET IF MORE SPACE IS NEEDED)

Applicants that desire to drive in intrastate/interstate commerce must provide the following information on all employers during the previous three years. You must give the same information for all employers you have driven a commercial motor vehicle for the seven years prior to the initial three years (total of ten years employment record).

Must list the complete mailing address: street number and name, city, state and zip code.

LAST EMPLOYER: NAME ___________________________________________________________________________

ADDRESS __________________________________________________ PHONE _____________________________

POSITION HELD ____________________________ FROM __________ TO ___________SALARY _______________

REASONS FOR LEAVING ___________________________________________________________________________

ANY GAPS IN EMPLOYMENT AND/OR UNEMPLOYMENT MUST BE EXPLAINED. INCLUDE DATES (MONTH/YEAR) ND REASON. ____________________________________________________________________________________ A

Were you subject to the Federal Motor Carrier Safety Regulations (FMCSRs) while employed by the previous employer? Yes No

Was the previous job position designated as a safety sensitive function in any DOT regulated mode, subject to alcohol and controlledubstances testing requirements as required by 49 CFR Part 40? Yes Nos

SECOND LAST EMPLOYER: NAME ___________________________________________________________________

ADDRESS __________________________________________________ PHONE _____________________________






THIRD LAST EMPLOYER: NAME _____________________________________________________________________

ADDRESS __________________________________________________ PHONE ______________________________






TO BE READ AND SIGNED BY APPLICANT I authorize you to make sure investigations and inquiries to 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 willbe 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

pplication. aIn the event of employment, I understand that false or misleading information given in my application or interview(s) may result in ischarge. I understand, also, that I am required to abide by all rules and regulations of the Company. d

“I understand that information I provide regarding current and/or previous employers may be used, and those employer(s) will becontacted, 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 current/previous employers;

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

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

______________________________________ ___________________________________________________________ DATE APPLICANT'S SIGNATURE

This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my nowledge. k

______________________________________ ___________________________________________________________ DATE APPLICANT'S SIGNATURE

Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations.

Page 14

SAFETY PERFORMANCE HISTORY RECORDS REQUEST PART 1: TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name) ________________________________________________________ ____________________________First M.I. Last Social Security Number

Hereby authorize: ____________________Date of Birth

Previous Employer: _____________________________________________________ Email: _____________________

Street: ____________________________________________________________ Telephone: _____________________

City, State, Zip: _______________________________________________________ Fax No.: _____________________

To release and forward the information requested by section 3 of this document concerning my Alcohol and ControlledSubstances Testing records within the previous 3 years from ________________________________.

(employment application date)

To: Prospective Employer: ________________________________________________________________

Attention: _________________________________ Telephone: ____________________

Street: ________________________________________________________________

City, State, Zip: ________________________________________________________________

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensuresconfidentiality, such as fax, email, or letter.

Prospective employer’s fax number: ___________________________________

Prospective employer’s email address: _________________________________

_________________________________________________________________ ____________________________Applicant’s Signature Date

This information is being requested in compliance with §40.25(g) and 391.23.

PART 2: TO BE COMPLETED BY PREVIOUS EMPLOYER ACCIDENT HISTORY

The applicant named above was employed by us. Yes No

Employed as __________________________ from (m/y) ______________________ to (m/y) ______________________

1. Did he/she drive motor vehicle for you? Yes No If yes, what type? Straight Truck Tractor-SemitrailerBus Cargo Tank Doubles/Triples Other (Specify) ________________________________________________

2. Reason for leaving your employ: Discharged Resignation Lay Off Military DutyIf there is no safety performance history to report, check here , sign below and return.

ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved theapplicant in the 3 years prior to the application date shown above, or check here if there is no accident register data forthis driver.

Date Location # Injuries # Fatalities Hazmat Spill1. __________________ ___________________ __________________ __________________ __________________

2. __________________ ___________________ __________________ __________________ __________________

3. __________________ ___________________ __________________ __________________ __________________

Please provide information concerning any other accidents involving the applicant that were reported to governmentagencies or insurers or retained under internal company policies: _____________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________________________________

Any other remarks:__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature: ____________________________________________________

Title: ______________________________ Date: ____________________

Page 15

PREVIOUS EMPLOYER – COMPLETE PAGE 2 PART 3 PART 3: TO BE COMPLETED BY PREVIOUS EMPLOYER

DRUG AND ALCOHOL HISTORY

If driver was not subject to Department of Transportation testing requirements while employed by this employer, pleasecheck here , fill in the dates of employment from _______________ to _______________, complete bottom of Part 3,sign, and return.

Driver was subject to Department of Transportation testing requirements from _______________ to _______________.

1. Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration?YES NO

2. Has this person tested positive or adulterated or substituted a test specimen for controlled substances?YES NO

3. Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol orcontrolled substance test?

YES NO4. Has this person committed other violations of Subpart B of Part 382, or Part 40?

YES NO5. If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed

rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please senddocumentation back with this form.

YES NO6. For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this

driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?YES NO

In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previousemployers in the previous 3 years prior to the application date shown on page 1.

Name: ___________________________________________________________________________________________

Company: ________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City, State, Zip: ____________________________________________________ Telephone: _____________________

Part 3 Completed by (Signature): ___________________________________________ Date: _____________________

PART 4a: TO BE COMPLETED BY PROSPECTIVE EMPLOYER This form was (check one) Faxed to previous employer Mailed Emailed Other __________________

By: __________________________________________________________________ Date: ______________________

PART 4b: TO BE COMPLETED BY PROSPECTIVE EMPLOYER Complete below when information is obtained.

Information received from: ____________________________________________________________________________

Recorded by: _______________________________________ Method: Fax Mail Email Telephone

Date: _____________________________________________ Other _____________________________________

INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PAGE 1 PART 1: Prospective Employee

• Complete the information required in this section

• Sign and date

• Submit to the Prospective Employer

PAGE 2 PART 4a: Prospective Employer

• Complete the information

• Send to Previous Employer

PAGE 1 PART 2: Previous Employer


• Sign and date

• Turn form over to complete SIDE 2 SECTION 3

PAGE 2 PART 3: Previous Employer


• Sign and date

• Return to Prospective Employer

PAGE 2 PART 4b: Prospective Employer

• Record receipt of the information

• Retain the form

Page 17

U.S. DEPARTMENT OF TRANSPORTATION MOTOR CARRIER SAFETY PROGRAM

INQUIRY TO STATE AGENCY FOR DRIVER’S RECORD

391.23

__________________________(Driver’s Name)

__________________________(Driver’s Operator’s Lic. No.)

__________________________(Driver’s Social Sec. No.)

Dear __________________,

The above listed individual has made application with us for employment as a driver. Applicant has indicated that the above numbered operator’s license or permit has been issued by your State to applicant and it is in good standing.

In accordance with Section 391.23(a)(1) and (b) of the Federal Motor Carrier Safety Regulations, we are required to make inquiry into the driving record during the preceding 3 years of every State in which an applicant-driver has held a motor vehicle operator’s license or permit during those 3 years.

Therefore, please certify to us what the individual’s driving record is for the preceding 3 years, or certify that no record exists if that be the case.

In the event that this inquiry does not satisfy your requirements for making such inquiries, please send us such forms of yours as are necessary for us to complete our inquiry into the driving record of this individual.

Respectfully yours,

____________________________________Signature of individual making inquiry

________________________________________

(printed) Name of person making inquiry

________________________________________

Title of person making inquiry

________________________________________

Motor Carrier Name

________________________________________________________________________________

Street Address City State Zip

Page 19

DRIVER’S ROAD TEST EXAMINATION

Driver’s Name_________________________________ Phone No.______________

Driver’s Address______________________________________________________

City_________________________ State__________________ Zip Code_________

The road test shall be given by the motor carrier or a person designated by it. However, a driver who is a motor carrier must be given the test by another person. The 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 or she can operate the vehicle and associated equipment that the motor carrier intends to assign.

Rating of Performance

__________ The pretrip inspection (as required by Sec. 392.7).

__________ Coupling and uncoupling of combination units, if the equipment he or she may drive includes combination units.

__________ Placing the equipment in operation.

__________ Use of vehicle’s controls and emergency equipment.

__________ Operating the vehicle in traffic and while passing other vehicles.

__________ Turning the vehicle.

__________ Braking and slowing the vehicle by means other than braking.

__________ Backing and parking the vehicle.

__________ Other explain: ______________________________________________________

___________________________________________________________________

Type of equipment used in giving test: ____________________________________________

Date _______________, 20 _____ Examiner’s Signature______________________________

If the road test is successfully completed, the person who gave it shall complete a certificate of driver’s road test.

Remarks ______________________________________________________________________

______________________________________________________________________________ Page 21

Certificate of Driver's Road Test

Instructions: If the road test is successfully completed, the person who gave it shall complete a certificate of the driver’s road test. The original or copy of the certificate shall be retained in the employing motor carrier’s driver qualification file of the person examined and a copy given to the person who was examined. (49 CFR 391.31(e)(f)(g))

Certification of Road Test

Driver’s Name ________________________________________________________________

Social Security Number ________________________________________________________

Operator’s or Chauffeur’s License Number _________________________________________

State ________________________________________________________________________

Type of Power Unit ____________________________________________________________

Type of Trailer(s) _____________________________________________________________

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)

(Title)

(Organization and Address of Examiner)

Page 23

Form MCSA-5875 OMB No. 2126-0006 Expiration Date: 9/30/2019

Medical Examination Report Form (for Commercial Driver Medical Certification)

U.S. Department of Transportation Federal Motor Carrier Safety Administration

Public Burden Statement A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

MEDICAL RECORD #

(or sticker)SECTION 1. Driver Information (to be filled out by the driver)

Last Name: First Name: Middle Initial: Date of Birth: Age:

Street Address: City: State/Province: Zip Code:

Driver's License Number: Issuing State/Province: Phone: Gender: M F

E-mail (optional): CLP/CDL Applicant/Holder*: Yes No

Driver ID Verified By**:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Yes No Not Sure

*CLP/CDL Applicant/Holder: See instructions for definitions. **Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver's license, passport.

DRIVER HEALTH HISTORY

Have you ever had surgery? If "yes," please list and explain below. Yes No Not Sure

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.

Yes No Not Sure

PERSONAL INFORMATION

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**

(Attach additional sheets if necessary)


Last Name: First Name: DOB: Exam Date:

DRIVER HEALTH HISTORY (continued)

Do you have or have you ever had: Yes NoNot Sure

1. Head/brain injuries or illnesses (e.g., concussion)

2. Seizures, epilepsy

3. Eye problems (except glasses or contacts)

4. Ear and/or hearing problems

5. Heart disease, heart attack, bypass, or other heart problems

6. Pacemaker, stents, implantable devices, or other heartprocedures

7. High blood pressure

8. High cholesterol

9. Chronic (long-term) cough, shortness of breath, or other breathing problems

10. Lung disease (e.g., asthma)

11. Kidney problems, kidney stones, or pain/problems withurination

12. Stomach, liver, or digestive problems

13. Diabetes or blood sugar problems

Insulin used

14. Anxiety, depression, nervousness, other mental health problems

15. Fainting or passing out

Yes NoNot Sure

16. Dizziness, headaches, numbness, tingling, or memory loss

17. Unexplained weight loss

18. Stroke, mini-stroke (TIA), paralysis, or weakness

19. Missing or limited use of arm, hand, finger, leg, foot, toe

20. Neck or back problems

21. Bone, muscle, joint, or nerve problems

22. Blood clots or bleeding problems

23. Cancer

24. Chronic (long-term) infection or other chronic diseases

25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

26. Have you ever had a sleep test (e.g., sleep apnea)?

27. Have you ever spent a night in the hospital?

28. Have you ever had a broken bone?

29. Have you ever used or do you now use tobacco?

30. Do you currently drink alcohol?

31. Have you used an illegal substance within the past two years?

32. Have you ever failed a drug test or been dependent on an illegal substance?

Other health condition(s) not described above: Yes No Not Sure

Did you answer "yes" to any of questions 1-32? If so, please comment further on those health conditions below. Yes No Not Sure

CMV DRIVER'S SIGNATURE

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.

Driver's Signature: Date:

SECTION 2. Examination Report (to be filled out by the medical examiner)

DRIVER HEALTH HISTORY REVIEW

Review and discuss pertinent driver answers and any available medical records. Comment on the driver's responses to the "health history" questions that may affect the driver's safe operation of a commercial motor vehicle (CMV).




Last Name: First Name: Exam Date:DOB:

TESTING

Pulse rate: Pulse rhythm regular: Yes No Height: feet inches Weight: pounds

Blood Pressure Systolic Diastolic

Sitting

Second reading (optional)

Other testing if indicated

Urinalysis Sp. Gr. Protein Blood Sugar

Urinalysis is required. Numerical readings must be recorded.

Protein, blood, or sugar in the urine may be an indication for further testing to rule out any underlying medical problem.

Vision

Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At least 70° field of vision in horizontal meridian measured in each eye. The use of cor-rective lenses should be noted on the Medical Examiner's Certificate.

Acuity Uncorrected Corrected Horizontal Field of Vision

Right Eye: 20/ 20/ Right Eye: degrees

Left Eye: 20/ 20/ Left Eye: degrees

Both Eyes: 20/ 20/ Yes No

Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors

Monocular vision

Referred to ophthalmologist or optometrist?

Received documentation from ophthalmologist or optometrist?

Hearing

Standard: Must first perceive whispered voice at not less than 5 feet OR average hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).

Check if hearing aid used for test: Right Ear Left Ear NeitherWhisper Test Results

Record distance (in feet) from driver at which a forced whispered voice can first be heard

Right Ear Left Ear

OR

Audiometric Test Results

Right Ear Left Ear

500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz

Average (right): Average (left):

PHYSICAL EXAMINATION

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if neglecting the condition could result in a more serious illness that might affect driving. Check the body systems for abnormalities.

Body System Normal Abnormal1. General

2. Skin

3. Eyes

4. Ears

5. Mouth/throat

6. Cardiovascular

7. Lungs/chest

Body System Normal Abnormal8. Abdomen

9. Genito-urinary system including hernias

10. Back/Spine

11. Extremities/joints

12. Neurological system including reflexes

13. Gait

14. Vascular system

Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver's ability to operate a CMV. Enter applicable item number before each comment.




Please complete only one of the following (Federal or State) Medical Examiner Determination sections:

MEDICAL EXAMINER DETERMINATION (Federal)

Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49):

Does not meet standards (specify reason):

Meets standards in 49 CFR 391.41; qualifies for 2-year certificate

Meets standards, but periodic monitoring required (specify reason):

Driver qualified for: 3 months 6 months 1 year other (specify):

Wearing corrective lenses Wearing hearing aid Accompanied by a waiver/exemption (specify type):

Accompanied by a Skill Performance Evaluation (SPE) Certificate Qualified by operation of 49 CFR 391.64 (Federal)

Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal)

Determination pending (specify reason):

Return to medical exam office for follow-up on (must be 45 days or less):

Medical Examination Report amended (specify reason):

(if amended) Medical Examiner's Signature: Date:

Incomplete examination (specify reason):

If the driver meets the standards outlined in 49 CFR 391.41, then complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h), as appropriate.

I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that to the best of my knowledge, I believe it to be true and correct.

Medical Examiner's Signature:

Medical Examiner's Name (please print or type):

Medical Examiner's Address: City: State: Zip Code:

Medical Examiner's Telephone Number: Date Certificate Signed:

Medical Examiner's State License, Certificate, or Registration Number: Issuing State:

MD DO Physician Assistant Chiropractor Advanced Practice Nurse

Other Practitioner (specify):

National Registry Number: Medical Examiner's Certificate Expiration Date:



MEDICAL EXAMINER DETERMINATION (State)

Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations):

Does not meet standards in 49 CFR 391.41 with any applicable State variances (specify reason):

Meets standards in 49 CFR 391.41 with any applicable State variances

Meets standards, but periodic monitoring required (specify reason):

Driver qualified for: 3 months 6 months 1 year other (specify):

Wearing corrective lenses Wearing hearing aid Accompanied by a waiver/exemption (specify type):

Accompanied by a Skill Performance Evaluation (SPE) Certificate Grandfathered from State requirements (State)

If the driver meets the standards outlined in 49 CFR 391.41, with applicable State variances, then complete a Medical Examiner's Certificate, as appropriate.

I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that to the best of my knowledge, I believe it to be true and correct.

Medical Examiner's Signature:

Medical Examiner's Name (please print or type):

Date Certificate Signed:

Medical Examiner's Address: City: State: Zip Code:

Medical Examiner's Telephone Number:

Medical Examiner's State License, Certificate, or Registration Number: Issuing State:

MD DO Physician Assistant Chiropractor Advanced Practice Nurse

Other Practitioner (specify):

National Registry Number: Medical Examiner's Certificate Expiration Date:

Instructions MCSA-5875

Instructions for Completing the Medical Examination Report Form (MCSA-5875)

I. Step-By-Step Instructions

Driver:

Section 1: Driver information

· Personal Information: Please complete this section using your name as written on your driver's license, yourcurrent address and phone number, your date of birth, age, gender, driver's license number and issuing state.

o CLP/CDL Applicant/Holder: Check "yes" if you are a commercial learner's permit (CLP) or com-mercial driver's license (CDL) holder, or are applying for a CLP or CDL. CDL means a licenseissued by a State or the District of Columbia which authorizes the individual to operate a class of acommercial motor vehicle (CMV). A CMV that requires a CDL is one that: (1) has a gross combina-tion weight rating or gross combination weight of 26,001 pounds or more inclusive of a towed unitwith a gross vehicle weight rating (GVWR) or gross vehicle weight (GVW) of more than 10,000pounds; or (2) has a GVWR or GVW of 26,001 pounds or more; or (3) is designed to transport 16 ormore passengers, including the driver; or (4) is used to transport either hazardous materials requiringhazardous materials placards on the vehicle or any quantity of a select agent or toxin.

o Driver ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo IDused to verify the driver's identity such as, commercial driver's license, driver's license, or passport, etc.

o Question: Has your USDOT/FMCSA medical certificate ever been denied or issued for less than

two years? Please check the correct box “yes” or “no” and if you aren't sure check the “not sure” box.

· Driver Health History:

o Have you ever had surgery: Please check “yes” if you have ever had surgery and provide a writtenexplanation of the details (type of surgery, date of surgery, etc.)

o Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet

supplements): Please check “yes” if you are taking any diet supplements, herbal remedies, orprescription or over the counter medications. In the box below the question, indicate the name of themedication and the dosage.

o #1-32: Please complete this section by checking the “yes” box to indicate that you have, or have ever had,the health condition listed or the “No” box if you have not. Check the “not sure” box if you are unsure.

o Other Health Conditions not described above: If you have, or have had, any other health condi-tions not listed in the section above, check “Yes” and in the box provided and list those condition(s).

o Any yes answers to questions #1-32 above: If you have answered “yes” to any of the questions inthe Driver Health History section above, please explain your answers further in the box below thequestion. For example, if you answered “yes” to question #5 regarding heart disease, heart attack,bypass, or other heart problem, indicate which type of heart condition. If you checked “yes” to ques-tion #23 regarding cancer, indicate the type of cancer. Please add any information that will be helpfulto the Medical Examiner.

· CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating

that the information you provided in Section 1 is accurate and complete.


Medical Examiner:

Section 2: Examination Report

· Driver Health History Review: Review answers provided by the driver in the driver health historysection and discuss any “yes” and “not sure” responses. In addition, be sure to compare the medicationlist to the health history responses ensuring that the medication list matches the medical conditionsnoted. Explore with the driver any answers that seem unclear. Record any information that the driveromitted. As the Medical Examiner conducting the driver's physical examination you are required tocomplete the entire medical examination even if you detect a medical condition that you considerdisqualifying, such as deafness. Medical Examiners are expected to determine the driver's physicalqualification for operating a commercial vehicle safely. Thus, if you find a disqualifying condition forwhich a driver may receive a Federal Motor Carrier Safety Administration medical exemption, pleaserecord that on the driver's Medical Examiner's Certificate, Form MCSA-5876, as well as on the MedicalExamination Report Form, MCSA-5875.

· Testing:

o Pulse rate and rhythm, height, and weight: record these as indicated on the form.

o Blood Pressure: record the blood pressure (systolic and diastolic) of the driver being examined. A second reading is optional and should be recorded if found to be necessary.

o Urinalysis: record the numerical readings for the specific gravity, protein, blood and sugar.

o Vision: The current vision standard is provided on the form. When other than the Snellen chart isused, give test results in Snellen-comparable values. When recording distance vision, use 20 feet asnormal. Record the vision acuity results and indicate if the driver can recognize and distinguishamong traffic control signals and devices showing red, green, and amber colors; has monocularvision; has been referred to an ophthalmologist or optometrist; and if documentation has beenreceived from an ophthalmologist or optometrist.

o Hearing: The current hearing standard is provided on the form. Hearing can be tested using either awhisper test or audiometric test. Record the test results in the corresponding section for the test used.

· Physical Examination: Check the body systems for abnormalities and indicate normal or abnormal foreach body system listed. Discuss any abnormal answers in detail in the space provided and indicatewhether it would affect the driver's ability to safely operate a commercial motor vehicle.

In this next section, you will be completing either the Federal or State determination, not both.

· Medical Examiner Determination (Federal): Use this section for examinations performed inaccordance with the FMCSRs (49 CFR 391.41-391.49). Complete the medical examiner determinationsection completely. When determining a driver's physical qualification, please note that English languageproficiency (49 CFR part 391.11: General qualifications of drivers) is not factored into thatdetermination.

o Does not meet standards: Select this option when a driver is determined to be not qualified andprovide an explanation of why the driver does not meet the standards in 49 CFR 391.41.

o Meets standards in 49 CFR 391.41; qualifies for 2-year certification: Select this option when adriver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate.


o Meets standards, but periodic monitoring is required: Select this option when a driver is deter-mined to be qualified but needs periodic monitoring and provide an explanation of why periodicmonitoring is required. Select the corresponding time frame that the driver is qualified and if select-ing other, specify the time frame.

· Determination that driver meets standards: Select all categories that apply to the driver'scertification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, drivingwithin an exempt intracity zone, etc.).

o Determination pending: Select this option when more information is needed to make a qualificationdecision and specify a date, on or before the 45 day expiration date, for the driver to return to themedical exam office for follow-up. This will allow for a delay of the qualification decision for asmany as 45 days. If the disposition of the pending examination is not updated via the National Regis-try on or before the 45 day expiration date, FMCSA will notify the examining medical examiner andthe driver in writing that the examination is no longer valid and that the driver is required to be re-examined.

· MER amended: A Medical Examination Report Form (MER), MCSA-5875, may only beamended while in determination pending status for situations where new information (e.g., testresults, etc.) has been received or there has been a change in the driver's medical status since theinitial examination, but prior to a final qualification determination. Select this option when a Medic-

al Examination Report Form, MCSA-5875, is being amended; provide the reason for the amendm- ent, sign and date. In addition, initial and date any changes made on the Medical Examination

Report Form, MCSA-5875. A Medical Examination Report Form, MCSA-5875, cannot be amended after an examination has been in determination pending status for more than 45 days or after a final qualification determination has been made. The driver is required to obtain a new phys-

ical examination and a new Medical Examination Report Form, MCSA-5875, should be completed. o Incomplete examination: Select this when the physical examination is not completed for any

reason (e.g., driver decides they do not want to continue with the examination and leaves) otherthan situations outlined under determination pending.

o Medical Examiner information, signature and date: Provide your name, address, phone number,occupation, license, certificate, or registration number and issuing state, national registry number,signature and date.

o Medical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner'sCertificate (MEC) expires.

· Medical Examiner Determination (State): Use this section for examinations performed in accordancewith the FMCSRs (49 CFR 391.41-391.49) with any applicable State variances (which will only be validfor intrastate operations). Complete the medical examiner determination section completely.

o Does not meet standards in 49 CFR 391.41 with any applicable State variances: Select thisoption when a driver is determined to be not qualified and provide an explanation of why the driverdoes not meet the standards in 49 CFR 391.41 with any applicable State variances.

o Meets standards in 49 CFR 391.41 with any applicable State variances: Select this option whena driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate.

o Meets standards, but periodic monitoring is required: Select this option when a driver is deter-mined to be qualified but needs periodic monitoring and provide an explanation of why periodicmonitoring is required. Select the corresponding time frame that the driver is qualified and if select-ing other, specify the time frame.

· Determination that driver meets standards: Select all categories that apply to the driver'scertification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, etc.).


o Medical Examiner information, signature and date: Provide your name, address, phone number,occupation, license, certificate, or registration number and issuing state, national registry number,signature and date.

o Medical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner'sCertificate (MEC) expires.

II. If updating an existing exam, you must resubmit the new exam results, via the Medical Examination

Results Form, MCSA-5850, to the National Registry, and the most recent dated exam will take

precedence.

III. To obtain additional information regarding this form go to the Medical Program's page on the Federal

Motor Carrier Safety Administration's website at http://www.fmcsa.dot.gov/regulations/medical.

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Page 35

Printed by authority of the State of Illinois. January 2017 - 1 - DSD DC 164.11

All requestors must complete Sections I, II, IV and V.SECTION IEnter the Driver’s License Number and/or the Name and Date of Birth of the driver(s) whose record(s) is being requested in the spacesbelow. PLEASE PRINT LEGIBLY.

DRIVER’S LICENSE NUMBER NAME (Last, First, Middle) DATE OF BIRTH GENDER______________________________________ ____________________________________ ____________________ __________________________________________________ ____________________________________ ____________________ __________________________________________________ ____________________________________ ____________________ __________________________________________________ ____________________________________ ____________________ __________________________________________________ ____________________________________ ____________________ ____________

SECTION II – REQUESTOR’S IDENTITYDriver’s License, Permit or ID Number:_____________________________________________________________________________For yourself: Yes No If no, complete Section III.

SECTION III – If you classified yourself as a representative or agent of anyone other than yourself in Section II, you must providethe following information. Complete Section IV on reverse.

If the record(s) you requested must be mailed, to which address above should it be mailed: Section II Section III

SECTION IV (Please see reverse.)

SECTION V – AFFIRMATION OF REQUESTOR

I affirm that the information in Sections I, II, III and IV are true and correct to the best of my knowledge. I understand that if anyof the information provided by me in these sections is knowingly false or misleading, administrative, civil and/or criminal actionsmay be taken against me. (Notarization required if mailing form.)

Notary Seal

Signature: ____________________________________ Date: ____________________

SECRETARY OF STATE USE ONLY

Identification Checked:______________________________________________________________________________________________________

Employee Signature: ______________________________________________________ Date: ________ - ________ - ________

Number of Certified Records: ________ x $12.00 = ________ Type of Record: __________________________________________

Number of Photocopies: ____________ x $ 1.00 = ________ Cash MO Check Credit Card

Number of Certifications: ____________ x $ 2.00 = ________

Name First M.I. Last________________________________________________________________________________________________________________________________ Residential Address________________________________________________________________________________________________________________________________ City State ZIP Code

Name of Person or Organization I am representing________________________________________________________________________________________________________________________________ Address of Person or Organization________________________________________________________________________________________________________________________________ City State ZIP Code

Driving Record Abstract Request Form

Office of the Secretary of State

Driver Services Department2701 S. DIRKSEN PKWY.SPRINGFIELD, IL 62723

217-782-2720www.cyberdriveillinois.com

Page 37

SECTION IV

Place an “X” in front of the category below that describes you concerning the record(s). Mark only one category per request form.Items within ( ) are for Secretary of State personnel.

Purpose of Request (This information must be provided if you mark a box that has an asterisk next to it.): ____________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

I AM:

* ■ the person named on the abstract requested. (AFF or PUB-FEE “S”)

* ■ a law enforcement or court official with an official need for the abstract(s) requested. Complete Section III. (CRT or EXT-NOFEE “L”)

* ■ a private investigative agency or security service licensed in Illinois for any purpose permitted under 625 ILCS 5/2-123 of theIllinois Vehicle Code. Complete Section III. (PUB-FEE-”H”)

Detective State Registration #: _____________________

* ■ the legal representative of the person(s) named on the abstract(s) requested. Complete Section III. (AFF or PUB-FEE-”R”) Attorney State Registration #: __________________________________________

■ an attorney not representing the person(s) named on the abstract(s) requested but needing the abstract(s) for legal businessinvolving the affected driver(s). Complete Section III. (PUB-FEE-”A”)Attorney State Registration #: ______________________________________

* ■ the parent/legal guardian of the minor person(s) (under age 18) named on the abstract(s) requested. I am submitting theminor’s signed and notarized consent to obtain his/her abstract. (AFF or PUB-FEE-”P”)

■ an immediate family member (parent/legal guardian, brother, sister, spouse, grandparent, child or grandchild) of the adult (age18 or older) named on the abstract(s) requested. I am submitting the adult’s signed and notarized consent to obtain his/herabstract. (PUB-FEE-”F”)Relationship: _________________________________________

■ a representative of a local, state or federal government agency, with an official business need for the abstract(s) requested tocarry out the agency function on this request form. Complete Section III. (EXT-NO FEE-”G”)If an elected official, office held: _________________________________________________

■ a representative of the insurance industry with a legitimate insurance business need for the abstract(s) requested. CompleteSection III. (PUB-FEE-”I”)

■ the employer, prospective employer, or representative of the employer or prospective employer of the person(s) named on theabstract(s) requested. I am submitting the employee’s signed and dated consent form. If I am coming into a facility, I willbring in the employees signed and dated consent form. The abstract(s) is needed for business purposes pertaining to theperson’s(s’) employment or prospective employment. Complete Section III. (PUB-FEE-”E”)

■ a representative of a financial institution with a legitimate business need for the abstract(s) requested. Complete Section III.(PUB-FEE-”B”)

■ a representative of a new or used vehicle dealership, vehicle rental agency, or tow truck operation with a legitimate businessneed for the abstract(s) requested. Complete Section III. (PUB-FEE-”D”)

■ none of the above. The abstract(s) requested will be mailed to you by the Secretary of State Driver Services Department inSpringfield in approximately 10 business days. The Secretary of State’s office will send a letter to each person for whom a drivingabstract is requested approximately 10 days prior to mailing his/her abstract(s) to you. The letter will inform the person(s) ofthe date of your purchase and your name. NOTE: The abstract(s) requested will not list the address or personal informationof the individual(s). (PUB-Fee ”N”)

Page 38

MOTOR VEHICLE DRIVER’S CERTIFICATION

OF VIOLATORS 391.27

I certify that the following is a true and complete list of traffic violations (other than parking violations) for which I have been convicted or forfeited bond or collateral during the past 12 months.

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 required to be listed during the past 12 months.

________________________________________________ _____________________________________________

(Date of Certification) (Driver’s Signature)

________________________________________________ _____________________________________________

(Motor Carrier’s Name) (Motor Carrier’s Address)

________________________________________________ _____________________________________________

(Reviewed by: Signature) (Title)

Page 39

U.S. DEPARTMENT OF TRANSPORTATION MOTOR CARRIER SAFETY PROGRAM

ANNUAL REVIEW OF DRIVING RECORD 391.25

___________________________________________ __________________________ Name (Last, First, M.I.) (Soc. Sec. No.)

This day I reviewed the driving record of the above named driver in accordance with 391.25 of the Federal Motor Carrier Safety Regulations. I considered any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations and the Hazardous Materials Regulations. I considered the driver’s accident record and any evidence that he/she violated laws governing the operation of motor vehicles, and gave great weight to violations, such as speeding, reckless driving and operation while under the influence of alcohol or drugs, that indicate that the driver has exhibited a disregard for the safety of the public. Having done the above, I find that:

[ ] the driver meets the minimum requirements for safe driving, or

[ ] the driver is disqualified to drive a motor vehicle pursuant to 391.15

________________ _______________________________________________ Date of Review Motor Carrier’s Name

___________________________________________Reviewed by: Signature and title





Page 41

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Page 43

driver’S Time reCord

Driver’s Name (print) ___________________ Employee No. _____________ Month ____________ Year ___________

DRIVERS MAY PREPARE THIS REPORT INSTEAD OF “DRIVER’S DAILY LOG” IF THE FOLLOWING APPLIES:

• Operates within 100 air-mile radius of headquarters.• Returns to headquarters and is released from work within 12 consecutive hours.• At least 8 consecutive hours off duty separate each 12 hours of duty.

INTERMITTENT DRIVERS

Shall complete this form for 7 days preceding any day driving is

performed.

This includes the preceding month.

dateStart Time “all duty”

end Time “all duty”

Total Hours

driving Hours

Truck number

Headquarters

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

To be prepared monthly by each DOT-certified driver unless time record is exclusively kept on Driver’s Daily Log. Indicate “days off.” Check box if no driving is performed during this month and the first 7 days of the following month. Mail this report to your Division Manger of Administration.

Page 45

DRIVER’S TIME RECORD – OPERATIONS WITHIN 150 MILE RADIUS

Drivers’ Name (print)_____________________Employee No. _____________Month_______Year______

This document is an example provided for reference. The format of the required information is at the carrier’s discretion.

DateStart Time“All Duty”

End Time“All Duty” Total Hours Driving Hours Truck No.

Normal WorkReporting Location

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Note: Employer must maintain and retain accurate time records for a period of 6 months showing the time the dutyperiod began, ended, and total hours on duty each day in place of records of duty status.

DRIVERS MAY PREPARE THIS REPORT INSTEAD OF “DRIVERS DAILY LOG” IF THE FOLLOWING APPLIES:

Driver operates property-carrying commercial motor vehicles which do not require a Commercial Driver’s License.

Driver operates within a 150 air-mile radius of their normal work reporting location.

Driver may drive a maximum of 11 hours after coming on duty following 10 or more consecutive hours off duty.

Driver may not drive after the 14th hour after coming on duty 5 days a week or after the 16th hour after coming on duty2 days a week.

Page 47

HOURS OF SERVICE RECORD FOR FIRST TIME OR INTERMITTENT DRIVERS

Instructions: When using a driver for the first time or intermittently, a signed

statement must be obtained, giving the total time on duty (driving and on

duty) during the immediate preceding seven days and the time at which

the driver was last relieved from duty prior to beginning work.

Name (Print) __________________________________________________________________

First Middle Last

DAY TOTAL TIME ON DUTY

1 _________________

2 _________________

3 _________________

4 _________________

5 _________________

6 _________________

7 _________________

_________________________________________________________

TOTAL _________________________

I hereby certify that the information contained herein is true to the best of my

knowledge and belief, and that my last period of release from duty was from

______________________________________to ______________________________________(Hour/Date) (Hour/Date)

Signature ____________________________________DATE ___________________________

Page 49

Driver’s Vehicle Inspection ReportCheck ANY Defective Item and Give Details under “Remarks.”

DATE: ____________________

TRuCk/TRACTOR NO. _________________

Air CompressorAir LinesBatteryBrake AccessoriesBrakesCarburetorClutchDefrosterDrive LineEngineFifth WheelFront AxleFuel TanksHeater

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

HornLights Head – Stop Tail – Dash Turn IndicatorsMirrorsMufflerOil PressureOn-Board RecorderRadiatorRear EndReflectorsSafety Equipment Fire Extinguisher Flags – Flares – Fuses Spare Bulbs & Fuses Spare Seal Beam

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

SpringsStarterSteeringTachographTiresTransmissionWheelsWindowsWindshield WipersOther

❏

❏

❏

❏

❏

❏

❏

❏

❏

❏

TRAILER(S) NO (S). ____________________

Brake ConnectionsBrakesCoupling ChainsCoupling (king) PinDoors

❏

❏

❏

❏

❏

HitchLanding GearLights – AllRoofSprings

❏

❏

❏

❏

❏

TarpaulinTiresWheelsOther

❏

❏

❏

❏

Remarks: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Condition of the above vehicle is satisfactory

Driver’s Signature _________________________________________________________________

Above Defects Corrected

Above Defects Need NOT Be Corrected For Safe Operation Of Vehicle

Mechanic’s Signature ______________________________________ Date ___________________

Driver’s Signature _________________________________________ Date ___________________

❏

❏

❏

Page 51

Inspection, Repair & Maintenance Record

VEHICLE IDENTIFICATION

___________________________________________________ ____________________________________________________MAKE SERIAL NUMBER

___________________________________________________ ____________________________________________________YEAR TIRE SIZE

___________________________________________________ ____________________________________________________COMPANY NUMBER/OTHER I.D. OWNER, IF LEASED

DATE OPERATION PERFORMED, INSPECTION AND/OR REPAIR

Page 53

Vehicle Service Due Status Report

VEHICLE IDENTIFICATION

___________________________________________________ ____________________________________________________MAKE SERIAL NUMBER

___________________________________________________ ____________________________________________________YEAR TIRE SIZE

___________________________________________________ ____________________________________________________COMPANY NUMBER/OTHER I.D. OWNER, IF LEASED

DATE OF INSPECTION

TYPE OF INSPECTION

MILEAGE AT TIME OF

INSPECTION

DATE NEXT INSPECTION

DUE

MILEAGE TYPE OF

INSPECTION DUE

INSPECTION DUE

Page 55

Annual Vehicle Inspection Report

Vehicle History RecordReport

NumberFLEET UNIT NUMBER

DATE

MOTOR CARRIER OPERATOR INSPECTOR’S NAME (PRINT OR TYPE)

ADDRESS THIS INSPECTOR MEETS THE QUALIFICATION REQUIREMENTS IN SECTION 396.19.

o YES

CITY, STATE, ZIP CODE VEHICLE IDENTIFICATION (3) AND COMPLETE o LIC. PLATE NO.

o VIN o OTHER

VEHICLE TYPE o TRACTOR o TRAILER o TRUCK

o (OTHER)

INSPECTION AGENCY/LOCATION (OPTIONAL)

VEHICLE COMPONENTS INSPECTED

ITEM OK NEEDS REPAIR

REPAIRED DATE

1. BRAKE SYSTEM

a. Service Brakes

b. Parking Brake System

c. Brake Drums or Rotors

d. Brake Hose

e. Brake Tubing

f. Low Pressure Warning Device

g. Tractor Protection Valve

h. Air Compressor

i. Electric Brakes

j. Hydraulic Brakes

k. Vacuum Systems

2. COUPLING DEVICES

a. Fifth Wheels

b. Pintle Hooks

c. Drawbar/Towbar Eye

d. Drawbar/Towbar Tongue

e. Safety Devices

f. Saddle-Mounts

3. EXHAUST SYSTEM

a. Any exhaust system determined to be leaking ot a pointforward of or directly below the driver/sleeper compartment.b. A bus exhaust system leaking or discharging to theatmosphere in violation of standards (1), (2), or (3).c. No part of the exhaust system of any motor vehicleshall be so located as would be likely to result in burning,charring, or damaging the electrical wiring, the fuelsupply, or any combustible part of the motor vehicle.

4. FUEL SYSTEM

a. Visible leak

b. Fuel tank filler cap missing

c. Fuel tank securely attached

5. LIGHTING DEVICES

All lighting devices and reflectors required by Section 393 shall be operable.

6. SAFE LOADING

a. Part(s) of vehicle or condition of loading such that thespare tire or any part of the load or dunnage can fallonto the roadway.

b. Protection against shifting cargo

ITEM OK NEEDS REPAIR

REPAIRED DATE

7. STEERING MECHANISM

a. Steering Wheel Free Play

b. Steering Column

c. Front axle beam and ALL steering components otherthan steering column

d. Steering Gear Box

e. Pitman Arm

f. Power Steering

g. Ball and Socket Joints

h. Tie Rods and Drag Links

i. Nuts

j. Steering System

8. SUSPENSION

a. Any U-bolt(s), spring hanger(s), or other axlepositioning part(s) cracked, broken, loose or missingresulting in shifting of an axle from its normal position.

b. Spring Assembly

c. Torque, Radius, or Tracking Components

9. FRAME

a. Frame Members

b. Tire and Wheel Clearance

c. Adjustable Axle Assemblies (Sliding Subframes)

10. TIRES

a. Tires on any steering axle of a power unit.

b. All other tires.

11. WHEELS AND RIMS

a. Lock or Side Ring

b. Wheels and Rims

c. Fasteners

d. Welds12. WINDSHIELD GLAZING

Requirements and exceptions as stated pertaining to any crack, discoloration or vision reducing matter (reference 393.60 for exceptions).

13. WINDSHIELD WIPERS

Any power unit that has an inoperative wiper, or missing or damaged parts that render it ineffective.

List any other condition which may prevent safe operation of this vehicle.

______________________________________________

______________________________________________

Instructions: Mark column entries to verify inspection: X OK, X NEEDS REPAIR, NA IF ITEMS DO NOT APPLY, REPAIRED DATE.CERTIFICATION: THIS VEHICLE HAS PASSED ALL THE INPECTION ITEMS FOR THE ANNUAL VEHICLE INSPECTION REPORT IN ACCORDANCE WITH 49 CFR 396.

Page 57

NORTH AMERICAN STANDARDINSPECTION PROCEDURE

1. PREPARE THE VEHICLE AND DRIVERInstruct the driver to remain at the con-trols, and turn the engine off. (Allow cooldown time for turbo-charged engines.)Place chock blocks in position begin-ning on the driver’s side, one in front,and one behind the driver axle tires orbetween the axles, and advise the driverthat the wheels have been chocked.

Have the driver place the transmis-sion in neutral and release all brakes.

Advise the driver in the use of handsignals. (Lamps and brakes.)

2. CHECK DRIVER’S REQUIREMENTS• DRIVER LICENSE (391.11)

Check for expiration date,birth date, status check.

• MEDICAL CERTIFICATE (391.41)Check for expiration date, cor-rective lenses, hearing aid, sig-natures. Canadian driver licenseservices as medical certificate.

• MEDICAL WAIVER (if applicable)(391.49)Check for expiration date, andmake sure form is completed. Notethe stated physical limitations.

• RECORD OF DuTY STATuS (395.8)(395.3)updated to last change of duty status,today’s date, legible handwriting, past7 days recorded, mileage, driving time,on duty time, vehicle numbers, carriername, signature.“Remarks” section may include loca-tions of duty status change, unusualcircumstances that delay the trip, andshipping document numbers or thename of the shipper. Check for writtenauthorization for interactive electronicrecording devices, if applicable.

• DRIVER VEHICLE INSPECTIONREPORT (396.11)Check for I.D. number of vehicle(s)inspected, record of defectsfound (if any), and signatures.

• SHIPPING PAPERS/BILL OF LADINGCheck for listings of hazardousmaterials indicated by the first en-try, an “X” in the H.M. column, or acontrasting color. Papers must bewithin arm’s reach and visible.

• SEAT BELT (392.16)Check for condition and usage

• ALCOHOL AND DRuGS (392.4) (392.5)Check for violations

3. CHECK FOR PRESENCE OFHAZARDOUS MATERIALS• PLACARDS

Check for the presence of placards, butuse caution even if none are posted.

• LEAkS, SPILLS, uNSECuRE CARGOWhen hazardous materials are pres-ent, be ESPECIALLY careful withleaks, spills, or unsecure cargo.

• MARkINGSCargo tanks and portable tankswill display markings on an orangepanel or placard. They indicate theI.D. number of the hazardous materi-als. There are exceptions to this rule.

• LABELSWhen containers are visible, labelswill identify the hazardous materials.There are exceptions to this rule.

4. INSIDE CAB• STEERING LASH

Measure amount of steering lash andcompare with Out-of-Service Criteria.

• STEERING COLuMNCheck for unsecure attachment.

5. FRONT OF TRACTOR• HEAD LAMPS, TuRN SIGNALS,

EMERGENCY FLASHERS (393.25)Check for improper color and operation.

• WINDSHIELD WIPERS (393.78)Check for improper operation. Twowipers are required unless one canclean the driver’s field of vision.

• WINDSHIELD (393.60)Check for cracks or other damage. Checkfor decals or stickers in field of vision.

6. STEERING AXLEINFORM THE DRIVER THAT YOU AREGOING UNDER THE VEHICLE, AND TOLISTEN FOR YOUR INSTRUCTIONS.• STEERING SYSTEM (BOTH SIDES)

(393.209) Check for loose, worn,bent, damaged or missing parts.Instruct the driver to rock the steeringwheel, and check key components:front axle beam, gear box, pitmanarm, drag link, tie rod, tie rod ends.

• FRONT SuSPENSION (BOTH SIDES)(393.207)Check for indications of misaligned,shifted, or cracked springs, loosenedshackles, missing bolts, springhang-ers unsecure at frame, and crackedor loose u-bolts. Also, check for

unsecure axle positioning parts and signs of axle misalignment.

• FRONT BRAkES (BOTH SIDES)(393.48)Check for missing, nonfunctioning,loose, contaminated, or cracked partson the brake system, such as brakedrum, shoes, rotors, pads, linings, brakechamber, chamber mounting push rods,slack adjusters.Check for “S” cam flip over. Be alert foraudible air leaks around brake compo-nents and lines.With the brakes released, mark thebrake chamber push rod at a pointwhere the push rod exits the brakechamber. Mark the push rods onboth sides at this time; all push rodswill be measured in ITEM 10.

• FRONT AXLECheck for cracks, welds, and obviousmisalignment.

• FRAME and FRAME ASSEMBLYCheck for cracks, or any defect thatmay lead to the collapse of the frame.

7. LEFT FRONT SIDE OF TRACTOR(393.205)• LEFT FRONT WHEEL & RIM

Check for cracks, unseated lockingrings, broken or missing lugs, studs orclamps. Bent or cracked rims, “bleed-ing” rust stains, loose or damagedlug nuts and elongated stud holes.

• LEFT FRONT TIRE (393.75)Check for improper inflation, seriouscuts, bulges.Check tread wear and measure majortread groove depth.Inspect sidewall for defects.Check for exposed fabric or cord.Radial and bias tires should notbe mixed on the steering axle.

8. LEFT SADDLE TANK AREA• LEFT FuEL TANk(S) (393.65)

Check for unsecure mounting, leaks, orother damage. Verify that the fuel cross-over line is secure. Check for unsecurecap(s).Check ground below tank forsigns of leaking fuel.

• TRACTOR FRAME (393.201)Check frame rails and cross members on the tractor just behind the cab, lookingfor cracks, bends, or excessive corrosion.

• EXHAuST SYSTEM (393.83)Check for unsecure mounting, leaks(under the cab), exhaust contacted byfuel or air lines or electrical wires.

9. TRAILER FRONT• AIR & ELECTRICAL LINES (393.28)

Lines between tractor and trailer shouldbe suspended and free of tangles andcrimps. They should have sufficient slack to allow the vehicle to turn. Inspect lineconnections for proper seating.Listen for audible air leaks.

• FRONT END PROTECTION (393.106)Check for height requirements.(Note exceptions.)

10. LEFT REAR TRACTOR AREA (393.205)• WHEELS, RIMS & TIRES

Inspect as described in ITEM 7.Check inside tire of dual for inflation andgeneral condition.Tires should be evenly matched (same

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circumference) on dual wheels. Without placing yourself between the tires on tandem axles, check for debris between the tires.

• LOWER FIFTH WHEEL (393.70)Check for unsecure mounting to theframe or any missing or damaged parts.Check for any visible space between theupper and lower fifth wheel plates.Verify that the locking jaws arearound the shank and not the headof the kingpin. Verify that the re-lease lever is sealed properly, andthat the safety latch is engaged.

• uPPER FIFTH WHEEL (393.70)Check for any damage to the weightbearing plate and its supports on thetrailer. Check kingpin condition.

• SLIDING FIFTH WHEEL Check for proper engagement of lockingmechanism (teeth fully engaged on rail).Check for worn or missing parts, mak-ing sure that the position does notallow the tractor frame rails to con-tact the landing gear during turns.

INFORM THE DRIVER THAT YOU ARE GOING UNDER THE VEHICLE. ENTER THE UNDERCARRIAGE IN VIEW OF THE DRIVER.• SuSPENSION (BOTH SIDES) (393.207)

Inspect as described in ITEM 6.Check for deflated or leading airsuspension systems.

• BRAkES (BOTH SIDES) (393.48)Inspect brakes as describedin ITEM 6. With brakes re-leased, mark the push rods.

11. LEFT SIDE OF TRAILER• FRAME AND BODY (393.20, 393.203)

Check for cracks and any indicationleading to collapse of the frame.

• CARGO SECuREMENT (393.100)Check for improper blocking or brac-ing, and unsecure chains or straps.Verify end gates are secured in stakepockets. Check tarp or canvas.

• WHEELS, RIMS, & TIRES (393.205)Inspect as described in ITEM 7.

• SLIDING TANDEM (393.70)Check for misalignment and position.Look for damaged, worn, or missingparts. Check locking mechanism; teeth oflocking mechanism must fully mesh withthose of the rail secured to the frame.

INFORM THE DRIVER THAT YOU ARE GOING UNDER THE VEHICLE. ENTER THE UNDERCARRIAGE IN VIEW OF THE DRIVER.• SuSPENSION (BOTH SIDES) (393.207)

Inspect as described in ITEM 6

• BRAkES (BOTH SIDES) (393.48)Inspect as described in ITEM 6. Withbrakes released, mark push rods.

12. REAR OF TRAILER• TAIL, STOP & TuRN LAMPS &

EMERGENCY FLASHERS (393.11)Check for improper color and operation.

• CARGO SECuREMENT (393.100)Inspect as described in ITEM 11. Alsocheck tailboard security. Verify endgates are secured in stake pockets,and rear doors are closed. Checkboth sides of trailer to insure protec-tion of cargo from shifting or falling.

13. RIGHT SIDE OF TRAILER• CHECk ALL ITEMS AS ON LEFT SIDE.

14. RIGHT REAR TRACTOR AREA• CHECk ALL ITEMS AS ON LEFT SIDE.

15. RIGHT SADDLE TANK AREA• CHECk ALL ITEMS AS ON LEFT SIDE.

16. RIGHT FRONT SIDE OF TRACTOR• CHECk ALL ITEMS AS ON LEFT SIDE.

17. BRAKE ADJUSTMENT CHECKINFORM THE DRIVER THAT YOUARE GOING UNDER THE VEHICLE. ENTER THE UNDERCARRIAGEIN VIEW OF THE DRIVER.• MEASuRE PuSH ROD TRAVEL (ALL

BRAkES) (393.48)While the brakes are applied, movearound the vehicle and measure thedistance of push rod travel at eachchamber.Write down each push rod measure-ment, and compare them to the Out-of-Service Criteria for the appropriate sizeand type of brake chamber. Again, listenfor leaks as you move around the vehicle.

18. FIFTH WHEEL MOVEMENT CHECK(393.70)• uSE CAuTION

If conducted improperly, this method ofchecking for fifth wheel movement canresult in serious damage to the vehicle.use caution and instruct the drivercarefully.

• PREPARE THE VEHICLE AND DRIVERHave the driver put the vehicle in gear,release the service brakes, and apply thetrailer brakes. Remove the wheel chocksand have the driver start the vehicle.Carefully explain the procedure to thedriver. Tell the driver to GENTLY rockthe tractor as you watch the fifth wheel.

• CONDuCT THE PROCEDuREAs the tractor rocks, watch for move-ment between the mounting components and frame, pivot pin and bracket, andthe upper and lower fifth wheel halves.

19. AIR LOSS RATE (393.50)• WHEN TO CONDuCT THE TEST

If you heard an air leak at any pointin the inspection, you should nowcheck the vehicle’s air loss rate.

• CONDuCT THE PROCEDuREHave the driver run the engine at idle,then apply and hold the service brake.Observe the air reservoir pressuregauge on the dash. Have driver pumpthe pressure down to 80 psi.Compressors do not activate untilsystem pressure drops below a certainlevel. At about 80 lbs most compressorsshould be operating.Air pressure should be maintainedor increase. A drop in pressure indicatesa serious air leak in the brake system,and the vehicle should be placed outof service.

20. LOW AIR PRESSURE WARNING DEVICE(393.51)• TEST THE WARNING DEVICE

Instruct the driver to pump the air downuntil the low air pressure warning deviceactivates.Observe the gauges on the dash.The low air pressure warning mustactivate at a minimum of 1/2 thecompressor governor cut out pres-sure, approximately 55 psi.

21. TRACTOR PROTECTION VALVEThis procedure will test both thetractor protection valve and thetrailer emergency brakes.

• CONDuCT THE TESTInstruct the driver to release theemergency brakes by pushing in thedash valves.Break the supply emergency line atthe hose couplers between the trac-tor and the trailer. When the line isdisconnected, a blast of air will benoticed. At this point, the emergencybrakes on the trailer should set up.

• OBSERVE THE DASH GAuGEAir will leak from the tractor side of theline until the pressure in the tractor’ssystem drops to the 20-45 psi range.At that point, the air loss should stop,isolating the tractor air system. A lossof air in the tractor system below the20-45 psi range indicates a malfunc-tioning tractor protection valve. If thetrailer brakes do not set up when theline is disconnected, there is a problemwith the trailer emergency brakes.

22. COMPLETE THE INSPECTION• COMPLETE PAPER WORk

Complete inspection forms andother paperwork, as required.

• CONCLuDE WITH THE DRIVERExplain any violations or warningsto the driver. Take appropriate en-forcement action, if necessary.

• APPLY C.V.S.A. DECAL Apply a C.V.S.A. decal onall vehicles that qualify.

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LETTER OF OFF-DUTY AUTHORIZATION

This letter authorizes our driver _________________________

to be Off-Duty during meal and other routine stops.

The purpose of the Federal Department of Transportation Hours of Service

Regulations (Part 395) is to keep tired drivers from operating vehicles. Under

certain circumstances, however, it appears that enroute stops for meals

or other routine purposes may serve to lessen a driver’s fatigue.

Therefore, this letter is authorization for you to record your meal or other routine stops

on your logs as Off-Duty, rather than On-Duty Not Driving as would normally be the

case. However, this may be done only under all of the following circumstances.

1. Your vehicle must be parked in a safe and secure

manner so as to prevent obstruction of traffic and

theft or damage to the vehicle and cargo.

2. The off-duty period must be no less than 30

minutes and no longer than 60 minutes.

3. During the off-duty period, you are relieved from

responsibility from your vehicle and cargo.

4. During the off-duty period, you are free to leave

the premises on which your vehicle is parked and to

pursue activities of your choosing, as long as your

ability to safely operate your vehicle is not impaired

as required by part 392, “Driving of Vehicles”, of

the Federal Motor Carrier Safety Regulations.

_______________________________________________ ______________________________Driver Supervisor Date

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Examples of Drivers Lists

Last Name First Name Date of Birth Date of Hire License Number

Smith Jane 05/12/1968 02/20/2005 S530-4406-8736

Johnson Wilbur 12/20/1985 07/18/2009 J525-8808-5361

Evergreen Silas 02/06/1972 09/27/1999 E162-7807-2046-12

Or

Name, Date of Birth, License Number, License State, Date of Hire,

• Jane Smith, 05/12/1968, S530-4406-8736, IL, 02/20/2005

• Wilbur Johnson, 12/20/1985, J525-8808-5361, IL, 07/18/2009

• Silas Evergreen, 02/06/1972, E162-7807-2046-12, WI, 09/27/1999

License State

IL

IL

WI

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Example Vehicle Lists

Unit Number VIN License Plate State License Plate Number

1 2LMNOAPR05C046931 MA AB1234

2 2HSCHAJL09U046621 CT CD9876

3 2HSXYAPR05C267431 NH XY5466

OR

Type of Vehicle / Gross Vehicle Weight Year, Make, Model

Vehicle Identification No. (VIN)

License Plate No. / Company No.

List ALL equipment utilized in the past 365 days

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