Safety Performance History Records Request Details

Blank History Records Request is a website that provides easy to use instructions for requesting records from the federal government. This site has been created by the National Security Archive, a non-profit organization dedicated to preserving and publishing declassified materials from U.S. national security history with an emphasis on cyber policy, intelligence matters, and diplomacy. The National Security Archive works in collaboration with other libraries and organizations such as George Washington University's Gelman Library or Columbia University's Rare Book & Manuscript Library to publish documents online for public access.

Here is some information that will help you identify how much time it requires to finalize the blank history records request.

QuestionAnswer
Form NameBlank History Records Request
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesperformance history records request, safety performance history records request No Download Needed, request for driver's safety performance history, safety performance history request template fillable

Form Preview Example

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 Controlled Substances 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 ensures confidentiality, 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-Semitrailer

Bus

Cargo Tank

Doubles/Triples

Other (Specify) ________________________________________________

2.

Reason for leaving your employ: Discharged

Resignation

Lay Off

Military Duty

 

If 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 the applicant in the 3 years prior to the application date shown above, or check here if there is no accident register data for this driver.

Date

Location

# Injuries

# Fatalities

Hazmat Spill

1.__________________ ___________________ __________________ __________________ __________________

2.__________________ ___________________ __________________ __________________ __________________

3.__________________ ___________________ __________________ __________________ __________________

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

_________________________________________________________________________________________________

__________________________________________________________________________________________________

Any other remarks:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature: ____________________________________________________

Title: ______________________________ Date: ____________________

 

 

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, please check 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 or

 

controlled substance test?

 

YES

NO

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

YES NO

5.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 send documentation back with this form.

YES NO

6.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 previous employers 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

Complete the information required in this section

Sign and date

Turn form over to complete SIDE 2 SECTION 3

PAGE 2 PART 3: Previous Employer

Complete the information required in this section

Sign and date

Return to Prospective Employer

PAGE 2 PART 4b: Prospective Employer

Record receipt of the information

Retain the form

RECORDS REQUEST FOR

DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY

This request is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety-performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

PART 1:

COMPLETED BY THE DRIVER/APPLICANT

TO:

Prospective Employer: ________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ____________________________________ Telephone # _____________________

FROM:

Driver/Applicant: _____________________________ Social Security/I.D. # _____________________

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone # _____________________

I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records.

This information should be:

sent to me at the above address.

 

 

 

 

I will arrange to pick up.

 

 

 

Driver/Applicant Signature: ___________________________________________

Date: _______/_______/_______

 

 

M

D

Y

PART 2:

COMPLETED BY THE PROSPECTIVE EMPLOYER

The information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business- days deadline will begin when the prospective employer receives the requested safety performance history information.

Information supplied to:

Name: ___________________________________________________________________________________________

Street: ____________________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________________

Comments: _______________________________________________________________________________________

__________________________________________________________________________________________________

By:

 

 

 

 

_______________________________________________

______________ Release Date: _______/_______/_______

Signature/person providing information

Telephone #

M

D

Y

COPY 1 PROSPECTIVE EMPLOYER

SAFETY PERFORMANCE HISTORY INFORMATION

DRIVER/APPLICANT REBUTTAL

This rebuttal is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(j)(3) Drivers wishing to rebut information in records received pursuant to paragraph (i) of this section must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance history.

§391.23(j)(4) After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must:

(i) Forward a copy of the rebuttal to the prospective motor carrier employer;

(ii)Append the rebuttal to the driver’s information in the carrier’s appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirements.

PART 1:

COMPLETED BY THE DRIVER/APPLICANT

TO:

Previous Employer: ___________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ______________________________________________________________________

Telephone: ________________________________ Fax: ___________________________________

FROM:

Driver/Applicant: ____________________________________ ________________________________

Social Security #

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone No.: ___________________

I have submitted this rebuttal to my previous employer requesting that it be attached to my Safety Performance History and provided to subsequent prospective employers.

Reason for the rebuttal (attach documents as necessary): ___________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I request that this rebuttal be sent to the attached list of motor carriers.

Driver/Applicant Signature: _____________________________________________ Date: _______/_______/_______

M D Y

PART 2:

COMPLETED BY THE PREVIOUS EMPLOYER

Received by:

Signature: ___________________________________________________________ Date: _______/_______/_______

M D Y

COPY 1 PREVIOUS EMPLOYER

CORRECTION REQUEST

OF

ERRONEOUS SAFETY PERFORMANCE HISTORY INFORMATION

This request is made by the driver/applicant in compliance with the Department of Transportation regulations, §391.23, investigations and inquiries, paragraphs (j)(1) and (2) as printed below.

§391.23(j)(1) Driver wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer.

§391.23(j)(2) After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver’s request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver’s safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.

PART 1:

COMPLETED BY THE DRIVER/APPLICANT

TO: Prospective Employer: ________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ____________________________________ Telephone # ______________________

FROM: Driver/Applicant: _____________________________________________________________________

Social Security/I.D. # ________________________

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone # ______________________

I request correction of erroneous information in my Safety Performance History. Please forward to the following prospective employer: Company Name: ______________________________________

Attention: ____________________________________________

Street: ______________________________________________

City, State, Zip: _______________________________________

Explanation of desired correction (attach documents as necessary)____________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Driver/Applicant Signature: ______________________________________________ Date: _______/_______/_______

M D Y

Driver: Retain COPY 4 DRIVER RECORD for your files, Submit copies 1, 2, and 3 to your previous employer.

PART 2:

COMPLETED BY THE PREVIOUS EMPLOYER

Disposition of the requested information:

Information was corrected and forwarded to the prospective motor carrier employer.

The driver was notified on _____/_____/_____ that the previous employer does not agree to correct the data.

Return copy 3 to the driver.

Information sent to: Company Name: ____________________________________

Attention: __________________________________________

Street: ____________________________________________

City, State, Zip: _____________________________________

Comments: _______________________________________________________________________________________

__________________________________________________________________________________________________

By: ________________________________________

__________________ Release Date: ______/_______/_______

Signature/person providing information

Telephone #

M

D

Y

PART 3:

COMPLETED BY THE PROSPECTIVE MOTOR CARRIER EMPLOYER

The corrected information was received on _____/_____/_____

Prospective Employer: ______________________________ Location: _______________________________________

Received by: __________________________________________

__________________________________________

Signature

Title

COPY 1 PROSPECTIVE EMPLOYER

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