Form DS-873 at a glance
What it is: The certified examiner's report on annual defensive driving performance for a driver under Article 19-A.
A filled-in Form DS-873 example: an examiner observes a bus driver
How to fill out Form DS-873, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Section 1 - Driver Information
In Section 1, write the Driver's Last Name, First name and M.I., the Date of Birth (Month/Day/Year), and the License Class, Endorsements, Restrictions, Expiration Date, Driver License ID Number and State Licensed.
Section 2 - Carrier Information
In Section 2, write the Carrier/DBA Name, the Legal Name (if different), the Federal ID Number and the 19-A Business ID Number.
Section 3 - Vehicle Information
In Section 3, write the Type of Vehicle, Adult Seating Capacity, GVWR, Vehicle Plate Number and State.
Section 4 - Observation
Regular observation of a driver's defensive driving performance must be conducted while the driver is operating the vehicle with passengers, and the observation may be conducted either inside or outside of the bus that the driver is operating.
In Section 4, mark Observation Conducted: Inside or Outside.
Mark 1. Observation, 2. Traffic Lane Use (include center line violation), 3. Speed, 4. Properly Signals Intention, 5. Turning, 6. Vehicle Control, 7. Obeys Traffic Signs, Signals and Road Hazard Signs, 8. Observes Proper Following Distance, 9. Procedures for Receiving and Discharging Passengers, 10. Traffic Interaction each SATISFACTORY or NEEDS IMPROVEMENT.
Mark 11. Pre-Trip Safety Briefing Proficiency for Stretch Limo Operators NOT APPLICABLE, SATISFACTORY or NEEDS IMPROVEMENT.
Write Comments: they are required if Needs Improvement is checked above.
The observation shall NOT be conducted on the same day as the biennial Behind-the-Wheel Road Test.
Section 5 - Driver Acknowledgement
In Section 5, the driver signs on the Driver's Signature line and writes the Date, acknowledging: I acknowledge discussion of my defensive driving performance with the examiner who observed and rated my performance.
Section 6 - Examiner's Certification
In Section 6, write the Certified Examiner's Name, the Certificate Number, Certification Class, Expiration Date, Endorsements, Restrictions, and the Examiner's Certification Driver License ID Number.
The examiner certifies that the report is, to the best of the examiner's knowledge, true and correct, that the examiner personally observed the driver's defensive driving performance, currently holds a valid examiner certification as required in accordance with Article 19-A of the New York State Vehicle and Traffic Law, and holds the appropriate class driver's license with the proper endorsements.
The examiner acknowledges and understands that knowingly making a false statement in connection with this report or in any proofs or reports in connection with it for the purpose of deceiving or substituting, or causing another person to deceive or substitute, in connection with this examination or report may subject the examiner to criminal prosecution for a misdemeanor or felony under the Vehicle and Traffic Law and/or Penal Law.
The Certified Examiner signs on the Certified Examiner's Signature line and writes the Date of Observation.
Sources
[1] Form DS-873 (10/25), Report on Annual Defensive Driving Performance for Driver Under Article 19-a (the Official source link on this page).