Form DS-872 at a glance
What it is: Carrier's Annual Review of Employee's Driving Record Under Article 19-A: this review must be completed with the driver's abstract(s) and must be dated 30 days prior to the date of the interview.
Who signs: Sign on the (Driver Signature) line and enter the (Date). Sign on the (Authorized Signature of Carrier Representative) line and enter the (Date of Interview).
A filled-in Form DS-872 example: a driver's review with one accident
How to fill out Form DS-872, box by box
Driver Information
Under DRIVER INFORMATION, enter the Driver's Last Name, First, M.I. and Date of Birth (Month/Day/Year), then the Class of Driver's License, Endorsements, Restrictions, Expiration Date, License ID Number (from Driver License) and State.
Carrier Information
Under CARRIER INFORMATION, enter the Carrier/DBA Name, Federal ID Number and 19-A Business ID Number, and the Legal Name (if different).
Accident Information
Mark YES or NO: Were you involved in ANY motor vehicle accident(s) during the past 12 months that do not appear on your abstract? If YES, complete the Accident Information section.
In the ACCIDENT INFORMATION section (if additional space is needed, use the back of this form), enter the Date of Accident and the Location City, State, Zip Code, County.
Briefly describe property damage, type of vehicle involved and approximate dollar value of damage for each vehicle.
Enter the Number of People Injured, and YES or NO to Were there any fatalities?
Record of Convictions
Mark YES or NO: Were you convicted of ANY traffic violation(s) (other than parking) or any crime(s) during the past 12 months that do not appear on your abstract? If YES, complete the Record of Convictions section.
In the RECORD OF CONVICTIONS section (if additional space is needed, use the back of this form), enter the Date of Violation, Date of Conviction, Of What Charge Were You Convicted?, mark CMV or Non-CMV for Type of Motor Vehicle Operated, and enter the Court Location City, State, Zip Code, County.
Driver Certification
Under DRIVER CERTIFICATION, the driver certifies that the information is a true and complete list of traffic violations (other than parking violations) for which the driver has been convicted or forfeited bond or collateral during the past 12 months, and accidents the driver was involved in during the past 12 months. If no violations or accidents are listed, the driver certifies that the driver has not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months, or has not been involved in any accidents during the past 12 months that are not already listed on the driver's license abstract.
Sign on the (Driver Signature) line and enter the (Date).
Carrier Certification
Under CARRIER CERTIFICATION, the carrier compared the information given by the driver with the attached driver's abstract of operating record and ensured that all accident and conviction details not appearing on the driver's abstract are listed on this form. I HAVE ATTACHED THE DRIVER'S ABSTRACT(S), DATED: fill in the date, which must be within 30 days prior to the date of this interview. The carrier interviewed this employee and certifies that this driver meets the standards for safe driving, has been instructed in, and is in compliance with, the provisions of Article 19-A, and is qualified to drive a bus.
Enter the (Print Name of Carrier Representative) and the (Title).
Sources
[1] Form DS-872 (10/25), Carrier's Annual Review of Employee's Driving Record Under Article 19-A, New York State Department of Motor Vehicles (the Official source link on this page).