Form DS-872 at a glance
What it is: DS-872 is the Carrier's Annual Review of Employee's Driving Record under Article 19-A.
Who signs: Sign on the Driver Signature line and enter the Date. Enter the Print Name of Carrier Representative and Title, sign on the Authorized Signature of Carrier Representative line and enter the Date of Interview.
A filled-in Form DS-872 example: a supervisor reviews one driver
How to fill out Form DS-872, box by box
Driver information
Under Driver Information, enter the Driver's Last Name, First name, M.I. and Date of Birth (Month/Day/Year).
Enter 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
Were you involved in ANY motor vehicle accident(s) during the past 12 months that do not appear on your abstract? YES or NO. If YES, complete the Accident Information section.
In Accident Information, enter the Date of Accident, the Location (City, State, Zip Code, County) and briefly describe the property damage, type of vehicle involved and approximate dollar value of damage for each vehicle; if additional space is needed, use the back of this form.
Enter the Number of People Injured. Were there any fatalities? YES or NO.
Record of convictions
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? YES or NO. If YES, complete the Record of Convictions section.
In Record of Convictions, enter the Date of Violation, the Date of Conviction, the charge you were convicted of, mark CMV or Non-CMV for the Type of Motor Vehicle Operated and enter the Court Location (City, State, Zip Code, County); if additional space is needed, use the back of this form.
Certification
You certify that the information on this form is a true and complete list of traffic violations (other than parking violations) for which you have been convicted or forfeited bond or collateral during the past 12 months, and accidents you were involved in during the past 12 months. If no violations or accidents are listed on this form, you certify that you have not been convicted or forfeited bond or collateral on account of any violation required to be listed during the past 12 months, or have been involved in any accidents during the past 12 months that is not already listed on your license abstract.
Carrier certification
Interview this employee and certify 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.
The driver's abstract(s) must be attached and must be dated within 30 days prior to the date of the interview. Compare the information given by the driver with the attached driver's abstract of operating record and ensure that all accident and conviction details not appearing on the driver's abstract are listed on this form.
Sources
[1] Form DS-872 (5/16), 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).