Blank History Records Request – Fill Out and Use This PDF

Blank History Records Request is a document that gives the subject access to their own medical history. The person can then share it with whomever they want, including insurance companies and employers.

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Blank History Records Request PDF 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.

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Question	Answer
Form Name	Blank History Records Request
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	performance history form, safety performance history records request, safety performance history records request download, performance history records

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

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

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

How to Edit Blank History Records Request Online for Free

Filling in safety performance history form is simple. Our team designed our software to make it user-friendly and uncomplicated and allow you to prepare any PDF online. Here are a couple steps that you need to stick to:

Step 1: At first, click the orange "Get form now" button.

Step 2: The file editing page is now open. Include information or enhance current information.

If you want to complete the form, type in the details the application will ask you to for each of the following sections:

portion of empty spaces in safety performance history request template fillable

Enter the appropriate information in the space The applicant named above was, ACCIDENT HISTORY, Employed as from my to my, Did heshe drive motor vehicle for, Reason for leaving your employ, ACCIDENTS Complete the following, Date, Injuries Fatalities Hazmat Spill, Location, Please provide information, and Any other remarks.

part 2 to completing safety performance history request template fillable

The program will request information to instantly fill up the area Signature, and Title Date.

Filling out safety performance history request template fillable stage 3

You will have to indicate the rights and obligations of every party in box If driver was not subject to, Driver was subject to Department, Has this person had an alcohol, YES cid NO cid, Has this person tested positive, YES cid NO cid, Has this person refused to submit, YES cid NO cid, Has this person committed other, YES cid NO cid, If this person has violated a DOT, YES cid NO cid, For a driver who successfully, YES cid NO cid, and In answering these questions.

part 4 to entering details in safety performance history request template fillable

Finalize by reviewing these areas and completing the appropriate data: Company, Street, City State Zip Telephone, Part Completed by Signature Date, PART a This form was check one cid, TO BE COMPLETED BY PROSPECTIVE, By Date, PART b Complete below when, TO BE COMPLETED BY PROSPECTIVE, Information received from, Recorded by Method cid Fax cid, Date cid Other, INSTRUCTIONS TO COMPLETE THE, PAGE PART Prospective Employee, and PAGE PART Previous Employer.

safety performance history request template fillable Company, Street, City State Zip Telephone, Part Completed by Signature Date, PART a This form was check one cid, TO BE COMPLETED BY PROSPECTIVE, By Date, PART b Complete below when, TO BE COMPLETED BY PROSPECTIVE, Information received from, Recorded by Method cid Fax cid, Date cid Other, INSTRUCTIONS TO COMPLETE THE, PAGE PART Prospective Employee, and PAGE PART Previous Employer fields to complete

Step 3: After you hit the Done button, your finalized document can be simply transferred to all of your devices or to email indicated by you.

Step 4: To prevent yourself from probable forthcoming troubles, be sure to hold around several duplicates of each and every document.

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