PSATS CDL PROGRAM
CMV/CDL DRIVER QUALIFICATION FILES (DQF)
PSATS CDL Program ▐ 4855 Woodland Drive ▐ Enola, PA ▐ 17025 ▐ (P) 717-763-0930 ▐ (F) 717-763-9732▐ (E) [email protected]
Pennsylvania’s intrastate commercial motor vehicle regulations (67 Pa. Code Chapter
231) now provide even more flexibility for local governments in hiring the employees necessary
for effective road maintenance operations. In accordance with 67 Pa. Code Chapter 231.8(6),
state and local governments and their regularly employed drivers who operate commercial motor
vehicles (CMV) in intrastate travel (within Pennsylvania) are exempt from needing to maintain
records regarding the driving qualifications of those employees. All other employers are still
required to maintain these records for their CMV employees.
However, the pre-employment drug test is still a requirement of all employers when
hiring an employee who will be operating CDL vehicles (any CMV weighing more than 26,001
pounds). Further, employees operating CDL vehicles must also posses a valid commercial
drivers license and be covered by the employer’s random drug and alcohol testing program
Pennsylvania regulations at 67 Pa. Code Chapter 231.8 define a CMV as any motor
vehicle or combination used on a highway in intrastate commerce to transport passengers or
property when the vehicle meets one of the following conditions:
(i) Has a gross vehicle weight rating or gross combination weight rating (GVWR), or
gross vehicle weight or gross combination weight, of 17,001 pounds or more,
whichever is greater.
(ii) Is designed or used to transport more than 8 passengers (including the driver) for
compensation.
(iii) Is designed or used to transport more than 15 passengers, including the driver, and
is not used to transport passengers for compensation.
(iv) Is a school bus.
(v) Is transporting hazardous materials which is required to be placarded in
accordance with Department regulations.
For the many municipalities that still require the maintenance of these records as a
condition of employment, provided below is a discussion of the forms that should be maintained
in each CMV employee’s “driver qualification file” (DQF), which should be kept current, and
stored in a secure location with controlled access.
1. Driver’s qualification file (DQF). Chart CDL FORM HIRING DQF represents the full array
of information and records that should be obtained at time of hire and kept in each CMV
driver’s qualification file (DQF) for the duration of this employee’s employment plus three
years. This form also lists the additional information needed to hire an employee who will be
operating CDL vehicles.
Chart CDL FORM DQF represents the full array of information and records needed each
additional year of this employee’s employment. This information must also be kept in the
employee’s DQF and retained in accordance with the enclosed GUIDANCE - RECORD
RETENTION SCHEDULE.
PSATS CDL PROGRAM
CMV/CDL DQF CONTINUED…
2. Written application for employment. All applicants for CMV employment should provide
a written application for employment using CDL FORM APPLY.
3. Pre-CDL employment drug test result. An applicant for employment that will require the
use of a CDL vehicle must obtain a negative result on a pre-CDL employment drug test prior
to performing CDL duties.
4. Requests for information. The new employer should maintain a written, confidential record
of the following information, or, if no records exist, of the good faith efforts you made to
obtain the information, such as a copy of your request for information. Failure by a past non-
municipal employer to respond to any authorized request for required information must be
reported by the new employer to the FMCSA in accordance with the enclosed GUIDANCE –
FMSCA COMPLAINT. Since Pa. municipalities are exempt from needing to maintain these
driver safety records, prospective employers should be informed if this is the reason that no
response was provided by a municipal employer. In all cases, the employee must sign a
release authorization section of each form sent to previous employers. Refusal to sign any
authorization would prevent the employee from being employed.
a. Review the results of the inquiries to state driver licensing agencies. Employers of
new CMV employees should obtain, within 30 days of such employment, information
about the new employee’s driving record for the past three years from every state in
which the new employee held a valid driver’s license and determine if that employee is
qualified to operate commercial motor vehicles. Employees should sign CDL Form
FCRA Disclosure thereby allowing the employer to electronically obtain the employee’s
drivers license information for the duration of such employment.
Employers must use PENNDOT FORM DL-503 to obtain information by mail for
Pennsylvania license holders and CDL FORM OTHER to request such information from
other states.
Upon receipt of this information, the employer should determine (using CDL FORM
INITIAL QUALIFY) if the employee is qualified to operate a CMV. The employer should
then use PENNDOT FORM DL-503 (or obtain an account with PennDOT to access such
information on-line) at least once every twelve months to determine that this employee
remains qualified to operate CMVs using CDL FORM QUALIFY.
Over …
PSATS CDL PROGRAM
CMV/CDL DQF CONTINUED…
b. Review past safety history. The new employer should use CDL FORM HISTORY to
obtain information about this employee’s safety performance history from all CMV
employers from the past three years within 30 days of hire. If an applicant does not have
any CMV experience in the past three years, the new employer must check the box in the
bottom paragraph indicating why no request for such information was made.
c. Review past test results. The new employer should use CDL FORM RESULTS to obtain
information about the new employee’s CDL drug and alcohol test results from all
employers for whom that employee performed CDL activities in the past three years
within 30 days of hire for any applicant for employment that will require the use of a
CDL vehicle. With respect to any employee who violated a DOT drug and alcohol
regulation, documentation of the employee's successful completion of return-to-duty
requirements (including follow-up tests) must also be obtained. If a previous employer
does not have information about the return-do-duty process, the new employer must seek
to obtain this information directly from the employee. If an applicant does not have any
CDL experience in the past three years, the new employer must check the box in the
bottom paragraph indicating why no request for such information was made.
5. Obtain employee’s signature acknowledging receipt of employer’s personnel policy
regarding CDL drug and alcohol testing. Each employee who will operate CDL vehicles
shall participate in the employer’s CDL drug and alcohol testing program and must sign CDL
FORM POLICY indicating they have received a copy of the employer’s CDL employee drug
and alcohol testing policy. This form must be permanently retained in the employee’s file.
Employers should then use CDL FORM ROSTER to add a new CDL employee to this
employer’s list of employees covered by its random drug and alcohol testing policy.
6. Pennsylvania New Hire Report and Federal New Hire Report (I-9) must both be filed as
appropriate: the Pa. New Hire Report must be sent to the state as indicated. Further, all
federal I-9 forms must be kept either for three years after the date of hire, or for one year
after employment is terminated, whichever is later.
7. All applicants for CMV employment must be given the information contained in GUIDANCE
- RIGHT TO REVIEW RESPONSES from previous employers at time of application. All applicants
should also be given the PennDOT form DISQUALIFICATIONS AND TRAFFIC OFFENSES fact
sheet detailing how they can be disqualified from operating CMVs.
8. Obtain employee’s signature acknowledging receipt of annual training, if any, using
CDL FORM TRAIN. These forms should also be retained in the employee’s file.
9. Notification of Suspension. Any employee whose driver’s license is suspended, revoked,
canceled, or if the driver is otherwise disqualified from driving, must notify each employer
by the end of the next business day following receipt of the notice of suspension, revocation,
cancellation, lost privilege or disqualification.
###
CMV/CDL Driver’s Qualification File
Time-of-Hire Documents Checklist
PSATS CDL Form Hiring DQF
Driver’s Name: _________________________________________
Driver license #: _________________________________________
Hire Date: _____________________________________________
Optional records when hiring municipal CMV driver (required records for hiring private sector CMV driver): Employment
Application
(Form APPLY)
Driving record
inquiry
(PennDOT
DL-503)
Initial driving
record review
(Form
QUALIFY)
Request past
test results
(Form
RESULTS)
Response(s)
received for
Form
RESULTS
Request past
safety history
(Form
HISTORY)
Response(s)
received for
Form
HISTORY
Medical
Examiners
Certificate
Expiration
Date *
Required records when hiring a municipal or private sector CMV driver: PA New Hire
Form
Federal I-9
Form
Required records when hiring any CDL driver: Date of
negative pre-
CDL drug test
CDL employee
testing policy
(Form
POLICY)
Name of drug/alcohol testing
program for this CDL
employee
NOTE: Put the date when any of these forms is added to this driver qualification file.
* = Medical examiners certificate not required for Pa. local government employees.
This form and any of the above-listed items must be kept for duration of CDL employment plus three years.
CMV/CDL Driver’s Qualification File
Annual Employment Documents Checklist
PSATS CDL Form Annual DQF
Driver’s Name: _________________________________________
Driver license #: _________________________________________
Hire Date: _____________________________________________
Optional records for continuing municipal CMV employment (required for private sector CMV employee): Next calendar year of
employment
Make driving record
inquiry to PennDOT
every 12 months
Employers’ review of
employee’s PennDOT
driving record (Form
QUALIFY)
Records required for continuing CDL employment: Next calendar year of
employment
Notice of conviction,
if any (Form
CONVICTION)
Accident reports, if
any (Form
ACCIDENT)
Changed CDL
employee testing
policy? (Form
POLICY)
Medical Examiners
Certificate Expiration
Date *
Name of drug/alcohol
testing program for
this CDL employee
NOTE: Put the date in the box when any of these forms is added to this driver qualification file.
* = Medical examiners certificate not required for local government CDL employees.
However, if this is otherwise required as a condition of employment, employer must keep track of expiration date.
Instructions for Completing the Form
ê Unless noted as optional, all required information must be included on the form.
ê Please type or print legibly in black or blue ink. ê This form may be duplicated.
FEIN: Federal Employer Identification Number Employer Name: Legal name of the employer Contact Name: Person authorized to answer questions on the
New Hire Report (this should be someone from the employer)
Contact Phone Number: Phone number for the contact person Employee Social Security Number:
The number assigned by the Social Security Administration
Date of Birth: Optional Item – date of birth for the new hire Date of Hire: The first day the new hire performs services for
wages Employee Name: First, Middle, and Last name of the new hire Employee Address: Permanent address of the new hire êê Pennsylvania New Hire Reports may be submitted through the mail or via
FAX. Mailing Address: Commonwealth of Pennsylvania
New Hire Reporting Program PO Box 69400 Harrisburg, PA 17106-9400
FAX Number: 717-657-HIRE 717-657-4473 1-866-748-4473 (TOLL FREE)
Customer Service Telephone Number:
1-888-PAHIRES 1-888-724-4737
217 COMMONWEALTH OF PENNSYLVANIA
New Hire Reporting Form
Required Employer Information FEIN: Please mail or fax to:
Employer Name: Commonwealth of Pennsylvania New Hire Reporting Program
Address: P. O. Box 69400 Harrisburg, PA 17106-9400
Fax: 717-657-HIRE (717-657-4473)1-866-748-4473 (TOLL FREE) Contact Name:
Phone: 1-888-PAHIRES (1-888-724-4737) Contact Phone #: (for questions only)
This form can be duplicated
Required Employee Information (Please type or print legibly in black or blue ink.)
Employee Social Security # Date of Birth (mm/dd/yyyy) optional Date of Hire (mm/dd/yyyy)
Name (first) (middle) (last)
Address
City State Zip
Employee Social Security # Date of Birth (mm/dd/yyyy) optional Date of Hire (mm/dd/yyyy)
Name (first) (middle) (last)
Address
City State Zip
Employee Social Security # Date of Birth (mm/dd/yyyy) optional Date of Hire (mm/dd/yyyy)
Name (first) (middle) (last)
Address
City State Zip
New Lending a HandHire to Pennsylvania's
Reporting Children
Commonwealth of Pennsylvania Department of Labor and Industry Center for Workforce Information and Analysis
Pennsylvania New Hire Reporting Program - 5REVISED 07/2010
Q: What is a disqualification?A: A disqualification is the temporary or permanent withdrawal of a person’s privilege to operate a commercial motor vehicle (CMV).
Q: How long can a disqualification last?A: The length of a disqualification depends on the violation as well as the driver’s record. It can be for a minimum of 60 days or as long as a lifetime.
Q: How does a Commercial Driver become disqualified?A: A disqualification can result from a single conviction for a MAJOR OFFENSE, an accumulation of SERIOUS TRAFFIC OFFENSES or for other
specific violations, i.e. violations of railroad-highway grade crossings.
Q: What is a major offense?A: The following chart lists the violations that are defined as major offenses for CDL holders. Most of these violations will result in the disqualification
of your commercial driving privilege regardless of the type of vehicle you are driving (CMV and non-CMV). The disqualification period that a majoroffense carries depends on the offense and the type of vehicle you are driving. Two major offenses result in a lifetime disqualification.
Lifetime
Federal Description PA Code Section Vehicle TypeLength of
Disqualificationfor First Offense
Driving under the influence of alcohol or controlledsubstance.
Refusing to submit to chemical testing.
Leaving the scene of an accident.
Using a vehicle to commit felony.
Using a vehicle in the commission of a felonyinvolving manufacturing, distributing or dispensing acontrolled substance.
Driving a CMV while the driver’s CDL is revoked,suspended, cancelled or disqualified.
Causing a fatality through the negligent operation ofa CMV.
3731(i)3802
16131547
37433745
Various CrimesCode Offenses
13a10 13a1413a19 13a3013a36
1606(c)(1)1543(a)(b)
3742 37352503 2504
CMV or Personal vehicle
CMV or Personal vehicle
CMV or Personal vehicle
CMV or Personal vehicle
CMV or Personal vehicle
CMV Only
CMV Only
1 Year3 Years with Hazmat
1 Year3 Years with Hazmat
1 Year3 Years with Hazmat
1 Year3 Years with Hazmat
1 Year3 Years with Hazmat
1 Year3 Years with Hazmat
Major Offenses
Q: What is a serious traffic offense (STO)?
A: The following chart lists the violations that are defined as serious traffic offenses. If you are convicted of any 2 of these serious traffic offenseswithin a 3 year period, you will be disqualified from driving a CMV for 60 days. If you are convicted of 3 or more serious traffic offenses within a3 year period, you will be disqualified from driving a CMV for 120 days. Most of these violations must occur in a CMV to count as a STO.However, there are some exceptions as noted below.
DISQUALIFICATIONS AND TRAFFIC OFFENSESFACT SHEET
June 2012
Federal Description PA Code Section Vehicle Type
Exceeding maximum speed limit 15 mph or more.
Driving recklessly, as defined by state or local law.
Making improper or erratic traffic lane changes.
Following the vehicle ahead too closely.
Duty of driver in construction and maintenance areasor on highway safety corridors. (This violation is anSTO under PA law)
Violating state or local law relating to motor vehicletraffic control arising in connection with a fatalaccident.
Driving a CMV without obtaining a CDL, driving aCMV without a valid CDL in the driver’s possession,driving a CMV without the proper class and/orendorsements.
3362 3365(b)
3736
3304 3305 3306(a)(1)3306(a)(2) 3306(a)(3) 33073309(1) 3309(2) 3309(4)
3310
3326
3714(b)All other moving violations
1606(a)1501(a)
CMVPersonal vehicle (only if the violation occurred ina work zone or school zone)
CMV or Personal vehicle
CMV
CMV
CMV
CMV or personal vehicleCMV only
CMV
Serious Traffic Offenses
CMVHazardous Grades 3365(c)
Q: Are there other violations that will result in a disqualification?A: Yes. Railroad-highway grade crossing violations, out-of-service order violations and being determined to constitute an imminent hazard.
Q: What is the disqualification period for a railroad-highway grade crossing offense?A: A conviction of a railroad-highway grade offense will result in the automatic disqualification of your privilege to operate a CMV if the offense
occured while operating a commercial vehicle. The length of the disqualification is 60 days for the 1st offense, 120 days for the 2nd offensewithing a 3 year period and 1 year for a 3rd or subsequent offense. The following chart lists the various railroad-highway grade crossingoffenses.
Federal Description PA Code Section Vehicle Type
The driver is not required to always stop, but fails to slow down and check that tracks areclear of an approaching train.
The driver is not required to stop, but fails to stop before reaching the crossing, if the tracksare not clear.
The driver is always required to stop, but fails to stop before driving onto the crossing.
The driver fails to have sufficient space to drive completely through the crossing withoutstopping.
The driver fails to obey a traffic control device or the direction of an enforcement official atthe crossing.
The driver fails to negotiate a crossing because of insufficient undercarriage clearance.
3342(g)
3342(g)
3342(a) 3342(e)
3341(b)(2) 3342(b)
3341(a) 3341(b)(1)
3343(a) 3343(c) 3343(d)
CMV
CMV
CMV
CMV
CMV
CMV
Railroad-Highway Grade Crossing Offenses
Q: What is the disqualification period for violating an out-of-service order?A: This is a tiered disqualification period. If a driver is convicted of violating an out-of-service order while transporting non-hazardous materials, 1st
offense - 1 year, 2nd or subsequent offense in a ten year period - 3 years. If a driver is transporting hazardous materials or operating a vehicledesigned to transport 16 or more passengers, including the driver, 1st offense - 2 years, 2nd or subsequent offense in a ten year period - 5years.
Q: What is an imminent hazard?A: The Federal definition of an imminent hazard is the existence of a condition that presents a substantial likelihood that death, serious illness, severe
personal injury, or a substantial endangerment to health, property, or the environment may occur before the reasonably foreseeable completiondate of a formal proceeding begun to lessen the risk of that death, illness, injury or endangerment.
Q: Who determines an imminent hazard?A: The Assistant Administrator or his/her designee from the Federal Motor Carrier Safety Administration (FMCSA).
Q: What is the length of disqualification imposed if a CDL holder is determined to be an imminent hazard?A: The period of disqualification should not exceed 30 days. However, the disqualification remains in effect until PennDOT is notified by the FMCSA
Assistant Administrator of his/her designee.
Q: Can an imminent hazard disqualification be appealed?A: Yes. The appeal can be filed with the Assistant Administrator, Adjudications Counsel, Federal Motor Carrier Safety Administration (Room 8217),
400 Seventh Street, SW., Washington, DC 20590.
Q: Do violations that occur out of state impact my Pennsylvania driving privilege?A: Yes. Out-of-state violations are treated as if they occured in Pennsylvania.
Q: Does the acceptance of Accelerated Rehabilitive Disposition (ARD) count towards disqualification?A: Yes. ARD participation is considered a conviction for sanctioning of CDL holders.
Q: Will an administrative per se suspension for a DUI arrest in another state affect my PA driving privilege?A: Yes. CDL holders that receive an administrative per se suspension will have their commercial driving privilege disqualified.
Q: Can a disqualified CDL driver operate a non-commercial vehicle?A: Yes. If a driver holds a CDL license or permit and is only disqualified from operating a CMV, the person is eligible to apply for a non-commercial
driver’s license to drive a non-commercial motor vehicle during the disqualification. An application to apply for a non-commercial license will beenclosed with the disqualification notice.
Q: How do I get my CDL privilege restored?A: In addition to serving the time required to the disqualification, you will have to pay a restoration fee to PennDOT before your CDL will be returned.
Q: How can I obtain additional information?A: You may write to the following address:
PennDOTP.O. Box 68618 OR CALL
Harrisburg, PA 17106-8618
Monday through Friday during the hours of8:00 a.m. - 5:00 p.m., Eastern Time
1-800-932-4600TDD: 1-800-228-0676
in state1-717-412-5300
TDD: 1-717-412-5380
out of state
The PSATS CDL Program acknowledges enrollment of the following
driver in our qualified testing consortium:
____________________________________________________
Federal law exempts local government employees from needing a medical card for interstate
commerce, while PA Code Title 67 Section 231.8(6) exempts local government
employees from needing a medical card for intrastate commerce.
Other important information for the driver is contained on the reverse.
PSATS CDL Program, 4855 Woodland Drive, Enola, PA, 17025
(P) 717-763-0930, (E) [email protected]
The PSATS CDL Program acknowledges enrollment of the following
driver in our qualified testing consortium:
____________________________________________________
Federal law exempts local government employees from needing a medical card for interstate
commerce, while PA Code Title 67 Section 231.8(6) exempts local government
employees from needing a medical card for intrastate commerce.
Other important information for the driver is contained on the reverse.
PSATS CDL Program, 4855 Woodland Drive, Enola, PA, 17025
(P) 717-763-0930, (E) [email protected]
The PSATS CDL Program acknowledges enrollment of the following
driver in our qualified testing consortium:
____________________________________________________
Federal law exempts local government employees from needing a medical card for interstate
commerce, while PA Code Title 67 Section 231.8(6) exempts local government
employees from needing a medical card for intrastate commerce.
Other important information for the driver is contained on the reverse.
PSATS CDL Program, 4855 Woodland Drive, Enola, PA, 17025
(P) 717-763-0930, (E) [email protected]
Important Driver Information Regarding Post-accident Testing
Section 49 CFR 382.303 requires the driver of a commercial motor vehicle involved in an accident (whether it involves
another vehicle or not) to take: (1) a DRUG AND ALCOHOL test if a fatality occurred; or (2) a DRUG AND ALCOHOL test if the
driver receives a citation for a moving traffic violation within 8 hours of the accident and either (a) any involved vehicle was
towed or (b) someone injured in the accident receives medical treatment away from the scene; or (3) a DRUG test if the driver
receives a citation for a moving traffic violation between 8 and 32 hours after the accident and either (a) any involved vehicle
was towed or (b) someone injured in the accident receives immediate medical treatment away from the scene.
Your employer is to identify here the name, address, and phone number of your nearest 24/7 PSATS CDL Program test site:
____________________________________________________________________________________________________
Phone #: _______________________________________. Should you need to take a post-accident test as defined above, you
must immediately contact this facility to inform them of your pending arrival so they may be ready. Unless medical attention
is required, you must take any alcohol test within 8 hours of the accident and you must take any any drug test within 32
hours of the accident. If unable to meet either of these time frames, the employer shall maintain a record in the employee’s
file stating the reason the test was not administered for submittal to any authorize authority upon request.
Important Driver Information Regarding Post-accident Testing
Section 49 CFR 382.303 requires the driver of a commercial motor vehicle involved in an accident (whether it involves
another vehicle or not) to take: (1) a DRUG AND ALCOHOL test if a fatality occurred; or (2) a DRUG AND ALCOHOL test if the
driver receives a citation for a moving traffic violation within 8 hours of the accident and either (a) any involved vehicle was
towed or (b) someone injured in the accident receives medical treatment away from the scene; or (3) a DRUG test if the driver
receives a citation for a moving traffic violation between 8 and 32 hours after the accident and either (a) any involved vehicle
was towed or (b) someone injured in the accident receives immediate medical treatment away from the scene.
Your employer is to identify here the name, address, and phone number of your nearest 24/7 PSATS CDL Program test site:
____________________________________________________________________________________________________
Phone #: _______________________________________. Should you need to take a post-accident test as defined above, you
must immediately contact this facility to inform them of your pending arrival so they may be ready. Unless medical attention
is required, you must take any alcohol test within 8 hours of the accident and you must take any any drug test within 32
hours of the accident. If unable to meet either of these time frames, the employer shall maintain a record in the employee’s
file stating the reason the test was not administered for submittal to any authorize authority upon request.
Important Driver Information Regarding Post-accident Testing
Section 49 CFR 382.303 requires the driver of a commercial motor vehicle involved in an accident (whether it involves
another vehicle or not) to take: (1) a DRUG AND ALCOHOL test if a fatality occurred; or (2) a DRUG AND ALCOHOL test if the
driver receives a citation for a moving traffic violation within 8 hours of the accident and either (a) any involved vehicle was
towed or (b) someone injured in the accident receives medical treatment away from the scene; or (3) a DRUG test if the driver
receives a citation for a moving traffic violation between 8 and 32 hours after the accident and either (a) any involved vehicle
was towed or (b) someone injured in the accident receives immediate medical treatment away from the scene.
Your employer is to identify here the name, address, and phone number of your nearest 24/7 PSATS CDL Program test site:
____________________________________________________________________________________________________
Phone #: _______________________________________. Should you need to take a post-accident test as defined above, you
must immediately contact this facility to inform them of your pending arrival so they may be ready. Unless medical attention
is required, you must take any alcohol test within 8 hours of the accident and you must take any any drug test within 32
hours of the accident. If unable to meet either of these time frames, the employer shall maintain a record in the employee’s
file stating the reason the test was not administered for submittal to any authorize authority upon request.
COMMERCIAL MOTOR VEHICLE
DRIVER ACCIDENT LOG
Today’s Date: _____________________________________________
Driver’s Full Name: ________________________________________
Driver License #: __________________________________________
Federal regulations at 49 CFR 390.15(b) require all employers to maintain at least the following
information regarding any accident (as defined below) of this driver for three years, as well as all other
accident reports required by State or other governmental entities or insurers.
The regulations at 49 CFR 390.5 define an “accident” as “an occurrence involving a commercial
motor vehicle operating on a highway in interstate or intrastate commerce which results in: (i) A fatality;
(ii) Bodily injury to a person who, as a result of the injury, immediately receives medical treatment away
from the scene of the accident; or (iii) One or more motor vehicles incurring disabling damage as a result
of the accident, requiring the motor vehicle(s) to be transported away from the scene by a tow truck or
other motor vehicle.”
The term accident does not include: (i) an occurrence involving only boarding and alighting from
a stationary motor vehicle; or (ii) an occurrence involving only the loading or unloading of cargo.
Date of accident: ______________________________
Municipality and state in which accident occurred: ____________________________________
Number of people injured: ________
Number of fatalities: ________
Were hazardous materials, other than fuel spilled from the fuel tanks of motor vehicles involved in the
accident, released? If “yes”, identify such materials here: ______________________________
_____________________________________________________________________________
PSATS CDL Program Form ACCIDENT
EMPLOYER’S NOTICE OF
CDL DRIVER’S CONVICTION
Today’s Date: _____________________________________________
Driver’s Full Name: ________________________________________
Driver License #: __________________________________________
Federal regulations at 49 CFR 383.31 require employees who have a CDL and operate commercial
motor vehicles to notify their current employer(s) and the state(s) which issued the license of any
conviction for violating, in any type of motor vehicle, a motor vehicle law (except parking). The
notification must be made (using this form) within 30 days of the date of that conviction.
Date of conviction: ______________________________
Location of offense: _____________________________
Identification of the specific laws violated for which I was convicted:
__________________________________________________________________________
__________________________________________________________________________
List any suspension, revocation, or cancellation of driving privileges resulting from such conviction(s);
__________________________________________________________________________
These violations did ( ) / did not ( ) occur while I was driving a commercial motor vehicle.
I certify by signing below that this is a true and complete
account of the events regarding this conviction.
__________________________________________________ Driver’s Signature
PSATS CDL Program Form CONVICTION