Form DS-875 at a glance
What it is: This form is the ARTICLE 19-A BIENNIAL BEHIND THE WHEEL ROAD TEST.
Who signs: The driver signs at Driver's Signature. The Certified Examiner signs at Certified Examiner's Signature and enters the Date of Test.
A filled-in Form DS-875 example: a driver who fails two 10 point items
How to fill out Form DS-875, 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 State Licensed, License Class, Endorsements, Restrictions, Expiration Date and Driver License ID Number.
The driver signs at Driver's Signature.
Carrier information
Under CARRIER INFORMATION, enter the Carrier/DBA Name, Legal Name (if different), Federal ID Number and 19-A Business ID Number.
Vehicle information
Under VEHICLE INFORMATION, enter the Type of Vehicle, Adult Seating Capacity, GVWR, Vehicle Plate Number and State.
1. PRE-TRIP TEST to 5. SIMULATED PROCEDURES, Point Value
In 1. PRE-TRIP TEST, A to E and G to K are 5 Point Value each, F. Failed to check seats and restraints when equipped is 5, and L. Failed to perform 50 ft. brake test is 10.
In 2. DEPARTING, A. Failed to signal is 5, B. Failed to observe is 10 and C. Failed to use caution is 10.
In 3. EN-ROUTE, A. Failed to properly signal is 5, B. Failed to observe is 10, C. Failed to demonstrate proper judgment approaching/at intersection is 10, D. Failed to make proper lane changes is 5, E. Failed to regularly check mirrors while driving is 5, F. Failed to stop properly at RR crossing is DQ, G. Failed to use proper clutch/engine control is 5, H. Failed to use proper judgment in traffic is 10 and I. Failed to demonstrate proper following distance is DQ.
In EN-ROUTE (Continued), J, K, L, M, O and R are 5, Q. Failed to use proper lane/s is 10, and N. Failed to use proper speed for conditions, P. Failed to yield right-of-way and S. Failed to observe traffic control devices are DQ.
In 4. PARKING AND BACKING, A. Failed to leave the vehicle to check rear before backing (no observer) is 10, D, E and F are 5, and B. Failed to observe (backing) and C. Unable to park are DQ.
In 5. SIMULATED PROCEDURES FOR RECEIVING/ DISCHARGING PASSENGERS, A, B, C and D are DQ: A. Failed to use caution at approaching/departing, receiving/discharging points, B. Failed to properly activate warning lights/devices (where applicable), C. Lacked knowledge of proper crossing procedures as required by NYS Education Department (where applicable) and D. Failed to observe pedestrians/passengers or other hazards at receiving and discharge points.
Results, if disqualified
RESULTS: QUALIFIED or DISQUALIFIED.
If disqualified, check all that apply: 40 or more points circled, One or more disqualification (DQ) item(s) circled, Any two, or more, 10 point items circled.
Examiner's certification
Under EXAMINER'S CERTIFICATION, enter the Certified Examiner's Name, Driver License ID Number, Certificate Number, Certification Class, Expiration Date, Endorsements and Restrictions.
The Certified Examiner certifies that the examiner currently holds a valid examiner certification as required in accordance with Article 19-A of the New York State Vehicle and Traffic Law, holds the appropriate class driver license with the proper endorsements, and has tested the above driver in compliance with Section 6.11 and/or Section 6.15 of Part 6 of the Commissioner's Regulations and reported the results to the employer. Knowingly making a false statement in connection with this 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 at Certified Examiner's Signature and enters the Date of Test.
More rules for Form DS-875
This test shall not be conducted on the same day as the annual defensive driving performance observation. The test should be taken without passengers in the vehicle.
If the driver fails the test, he/she is disqualified from driving under Article 19-A. The driver may make a request to the carrier for a reexamination.
Examiner use page 2 for any comments, under CERTIFIED EXAMINER'S COMMENTS.
Sources
[1] Form DS-875 (9/16), Article 19-A Biennial Behind the Wheel Road Test, New York State Department of Motor Vehicles (the Official source link on this page).