PSATS CDL PROGRAM CMV/CDL NEW HIRE RECORDS

PSATS CDL PROGRAM CMV/CDL NEW HIRE RECORDS Forms and other information used to support the hiring of an employee that will be operating CMV and/or CDL vehicles. NOTE: This document is formatted for two-sided printing. PSATS CDL Program 4855 Woodland Drive Enola, PA 17025 (P) 717-763-0930 (F) 717-763-9732 (E) cdl@psats.org

PSATS CDL PROGRAM CMV/CDL DRIVER QUALIFICATION FILES (DQF) 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 now 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 26,000 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) (v) Is a school bus. 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. Over PSATS CDL Program 4855 Woodland Drive Enola, PA 17025 (P) 717-763-0930 (F) 717-763-9732 (E) cdl@psats.org

PSATS CDL PROGRAM CMV/CDL DQF CONTINUED Chart CDL FORM DQF represents the full array of information and records that may be 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. 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 either obtain a negative result on a pre-cdl employment drug test or obtain an exemption from this testing using CDL FORM EXEMPT, 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 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. In all cases, the employee must sign the 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 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 employers in 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. ###

Driver s Name: CMV/CDL Driver s Qualification File Time-of-Hire Documents Checklist For Pa. Local Government Employees Driver license #: Hire Date: Optional records when hiring municipal 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 municipal CMV driver: PA New Hire Form Federal I-9 Form Required records when hiring municipal 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. PSATS CDL Form Hiring DQF Local Governments

CMV/CDL Driver s Qualification File Continuing Employment Documents Checklist For Local Government Employees Driver s Name: Driver license #: Hire Date: Optional records for continuing CMV employment : Next calendar year of employment Driving record inquiry every 12 months (PennDOT DL-503) Driving record review every 12 months (Form QUALIFY) Medical Examiners Certificate Expiration Date * Records required for continuing CDL employment *: Next calendar year of employment Notice of conviction (Form CONVICTION) Changed CDL employee testing policy (Form POLICY) Name of drug/alcohol testing program for this CDL employee Accident report (Form ACCIDENT) NOTE: Put the date when any of these forms is added to this driver qualification file. * = Medical examiners certificate not required for local government CMV employees. However, if this is otherwise required as a condition of employment, employer must keep track of expiration date. PSATS CDL Form DQF Local Government

PSATS CDL Program Guidance Record Retention Schedule General federal requirement. Each employer shall maintain the following original driver qualification records in a secure location with controlled access: Records to be retained for one year: CDL employee records of negative drug test results. CDL employee records of alcohol test results of less than 0.02. Records to be retained for three years: Records relating to the annual review of each CMV employee s drivers license information. All CMV employee s list of reported violations. Employer s annual calendar year or quarterly summaries of CDL drug and alcohol tests. CMV employee accident reports. Records to be retained for five years: CDL employee records of alcohol test results of 0.02 or greater. CDL employee records of positive drug test results. Record of CDL employee refusing to take any required CDL drug and/or alcohol test. Record concerning a CDL employee's compliance with recommended counseling. Records to be retained for duration of employment plus three years: Employee s written application for CMV employment. Results of pre-cmv employment request for driver license information. Results of pre-cmv employment request for past driver safety history. Results of pre-cdl employment request for CDL drug and alcohol test results. Record of supervisory employee s training to order probable cause CDL tests. ### PSATS CDL Program 4855 Woodland Drive Enola, PA 17025 (P) 800-CDL-7579 (F) 717-763-9732 cdl@psats.org

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New Employer Information: APPLICATION FOR CMV/CDL EMPLOYMENT All information must be obtained. Attach extra sheets if more space is needed for any of the following answers. Name Street Address City, State, Zip Contact Person Phone #: Applicant Information: Print Applicant s Name Date of Birth Current Address (Street) (City) (State) (Zip) Addresses for past three years: Address (Street) (City) (State) (Zip) Address (Street) (City) (State) (Zip) Nature and Extent of Driving Experience Type of equipment Date from: Date to: Total miles driven: List all Valid Commercial Motor Vehicle Licenses and/or Permits Issuing State License Number Expiration Date Commercial Motor Vehicle Accident Record (49 CFR 390.5) for past 3 years Date of accident: Nature of accident # Fatalities # Injuries Traffic Convictions (any vehicle, other than parking) and Bond Forfeitures in past 3 years Location Date Charge Penalty Over PSATS CDL Program Form APPLY

Operating Privileges Have you ever been denied a license, permit, or privilege to operate a motor vehicle? Has any license, permit, or privilege ever been suspended or revoked? Did you have a positive pre-employment drug or alcohol test in the past two years? Yes No Yes No Yes No If any answer is Yes, attach a statement giving details, including contact information for your counselor. Record of CMV Employment for Past 10 Years Note: If this employee has no history of CMV employment in last 3 years, check here (_). Last Employer Street Address City, State, Zip From: To: Reason for leaving Was this employment subject to FMCSRs (i.e., CMV)? (Y) (N) Was this employment subject to U.S. DOT alcohol and controlled substance testing (i.e., CDL)? (Y) (N) 2 nd Last Employer Street Address City, State, Zip From: To: Reason for leaving Was this employment subject to FMCSRs (i.e., CMV)? (Y) (N) Was this employment subject to U.S. DOT alcohol and controlled substance testing (i.e., CDL)? (Y) (N) 3 rd Last Employer Street Address City, State, Zip From: To: Reason for leaving Was this employment subject to FMCSRs (i.e., CMV)? (Y) (N) Was this employment subject to U.S. DOT alcohol and controlled substance testing (i.e., CDL)? (Y) (N) TO BE READ AND SIGNED BY APPLICANT By signing below, I certify that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge. Applicant s signature Today s Date NOTE: This employer may require an applicant to provide additional information than is required by FMCSRs for the purpose of investigating your work safety. Applicants also have additional rights regarding the information provided by previous employers, and may review previous employer-provided investigative information by submitting a written request to the new employer within 30 days after being employed or being notified of denial of employment.

PSATS CDL Program Guidance on Pre-Employment Drug Testing Pre-Employment Drug Testing Required An applicant for employment that will require the use of a CDL vehicle, or an existing employee beginning CDL work, must obtain a negative result on a pre-cdl employment drug test prior to first performing CDL duties for a new employer. No employer shall allow a new employee to perform any CDL work until the employer has received notice of a negative result for the preemployment drug test. Once a negative result has been received, the employer can then contact the PSATS CDL Program to add that employee to their roster. Exemption from Pre-Employment Drug Testing Available A new employer is not required to administer a pre-employment drug test on a new employee if the following conditions can be verified by the new employer. It should be noted, however, that even if the new employee meets the criteria for a waiver from the pre-employment testing requirement, the new employer can still require a pre-employment drug test of the new employee. 1. The new employee must have been in a CDL pool within the past 30 days for a previous employer; and 2. While participating in this pool, the employee must have either: (a) been tested for drugs in the six months prior to the date of application with the employer, or (b) been available, though not selected, for the previous 12 months; and 3. The new employer must contact all the new employee s previous employers for the past six months to determine if that employee had any violations of prohibited drug conduct. Any employer who grants an exemption to a pre-employment drug test shall contact the testing program in which the new employee participated and, using CDL Form EXEMPT on the reverse, obtain the information necessary to verify the employee s qualification for an exemption. Over

Verification of exemption from a pre-cdl employment drug test New Employer Any employer who grants an exemption to a pre-employment drug test shall contact the testing program in which the new employee previously participated and use this form to record the following information confirming the employee s exemption from needing a pre-cdl employment drug test: Employee s Name Did any past employer in the past two year have a record of this employee refusing any required CDL drug or alcohol test? Yes ( ) No ( ) Did this new employer obtain the results of all required CDL drug or alcohol tests the employee took for all other employers within the past 6 months? Yes ( ) No ( ) Employee s Past Testing Program Information Name of employee s previous testing program: Address of previous testing program: Contact person at previous testing program: Contact person phone number: Contact person confirms that program conforms to 49 CFR Part 40? ( ) Yes ( ) No Date employee first enrolled in this testing program: Date employee removed from this testing program, if any: Date employee was last tested by this testing program for drugs, if any: Note: When notifying the PSATS CDL Program of the addition of this employee to your roster of CDL employees by using CDL Form Change, write Exempt in the space that would otherwise have been used to identify the date of the pre-employment drug test. PSATS CDL Program Form EXEMPT

Employer s Copy PSATS CDL Program Guidance FMCSA Complaint. All employers are required to provide information to prospective employers regarding the safety history and test results of previous CMV employees. Prospective employers who do not receive this information shall report failures by previous employers to provide this information in accordance with the confidential complaint procedures specified at 49 CFR 386.12 and outlined below, and keep a copy of any complaint reports in the Driver Investigation file as part of documenting a good faith effort to obtain the required information. Complaint of substantial violation. Any person may file a written complaint with the Assistant Administrator (by mail at FMCSA, 400 7 th Street SW, Washington, DC, 20590 or by phone at 800-832-5660) alleging that a substantial violation of any regulation issued under the Motor Carrier Safety Act of 1984 is occurring or has occurred within the preceding 60 days. A substantial violation is one which could reasonably lead to, or has resulted in, serious personal injury or death. Each complaint must be signed by the complainant and must contain: The name, address, and telephone number of the person who files it; The name and address of the alleged violator and, with respect to each alleged violator, the specific provisions of the regulations that the complainant believes were violated; and A concise but complete statement of the facts relied upon to substantiate each allegation, including the date of each alleged violation. Over PSATS CDL Program 4855 Woodland Drive Enola, PA 17025 (P) 717-763-0930 (F) 717-763-9732 (E) cdl@psats.org

Employer s Copy Action on complaint of substantial violation. Upon the filing of a complaint of a substantial violation under paragraph (a) of this section, the Assistant Administrator shall determine whether it is nonfrivolous and meets the requirements of paragraph (a) of this section. If the Assistant Administrator determines the complaint is nonfrivolous and meets the requirements of paragraph (a), he/she shall investigate the complaint. The complainant shall be timely notified of findings resulting from such investigation. The Assistant Administrator shall not be required to conduct separate investigations of duplicative complaints. If the Assistant Administrator determines the complaint is frivolous or does not meet the requirements of the paragraph (a), he/she shall dismiss the complaint and notify the complainant in writing of the reasons for such dismissal. Confidentiality. Notwithstanding the provisions of section 552 of title 5, United States Code, the Assistant Administrator shall not disclose the identity of complainants unless it is determined that such disclosure is necessary to prosecute a violation. If disclosure becomes necessary, the Assistant Administrator shall take every practical means within the Assistant Administrator's authority to assure that the complainant is not subject to harassment, intimidation, disciplinary action, discrimination, or financial loss as a result of such disclosure. ### PSATS CDL Program 4855 Woodland Drive Enola, PA 17025 (P) 717-763-0930 (F) 717-763-9732 (E) cdl@psats.org

REQUEST FOR DRIVING RECORD FROM STATES WHICH ISSUED THIS DRIVER AN OPERATOR LICENSE IN PAST 3 YEARS Date: To: From: Driver Name: Driver Operators License #: Driver SSN: In accordance with federal regulations (49 CFR 391.23 (a)(1) and (b)), this employer must inquire, within 30 days from when the driver s new employment begins, about this driver s driving record from each State which issued the applicant an operators license or permit during the past 3 years. In the event this inquiry is not on the correct form, please send us your appropriate form. The above-named individual has made application with this employer for employment in a CMV capacity and indicated that the above-numbered operator s license or permit number has been issued by your State to this applicant within 3 years of today s date. Please provide a transcript of your records detailing this driver s driving record and return it and this form to our address above. AUTHORIZATION TO RELEASE REQUIRED INFORMATION I,, hereby specifically authorize this employer to obtain the information listed above as a condition of my performing CDL activities for this new employer. Driver s signature Date PSATS CDL Program Form OTHER

SECTION 603(X) FAIR CREDIT REPORTING ACT DISCLOSURE STATEMENT REGARDING DRIVER LICENSE REPORTS (Print name of prospective/current employer) In conjunction with my application for employment with the prospective employer named above that will require the operation of motor vehicles on public roads, I understand that the prospective employer intends to obtain information concerning my driver s license record from the state which issued my current driver s license at time of hire and regularly during my employment. I understand that this prospective employer may rely on the information provided by such state agency in determining whether to extend an offer of employment to me pursuant to Section 604 of the federal Fair Credit Reporting Act. I further understand that, if this prospective employer takes any adverse action (such as not offering me employment) based in whole or in part on this information, the prospective employer shall provide me a copy of the report containing the information obtained from the applicable state driver s license agency, including: 1. The name, address, and telephone number of the state agency that provided the report; 2. A statement that the state agency in question did not make the adverse decision and is not able to explain why the adverse decision was made; 3. A statement setting forth the applicant s right to obtain a free disclosure of the applicant s file from the state agency if the consumer makes a written request within 60 days; and, 4. A statement setting forth the applicant s right to dispute directly with the relevant state agency the accuracy or completeness of any information provided by such state agency. By signing below, I acknowledge having read the above disclosure and I hereby authorize the prospective employer (or its authorized agents) to obtain the above referenced information. Further, if I am hired, this authorization shall remain on file with the employer and shall serve as an ongoing authorization for this employer to obtain this same information about me at any time during my employment. Any copy of this authorization shall be as valid as the original. I also agree that any and all disputes arising from the prospective employer s use of this information shall be brought only in state or federal court in the Commonwealth of Pennsylvania, and shall be governed by, and construed in accordance with, the laws of the Commonwealth of Pennsylvania. Print Applicant s Name: Applicant s Signature: Today s Date: Note: This original form must be permanently maintained in this employee s personnel file. PSATS CDL Program Form FCRA Disclosure

CMV EMPLOYEE INITIAL REVIEW OF DRIVING RECORD Employer Name: Driver Name: Driver SSN: Federal regulation 49 CFR 391.25 requires employers to review, at time of hire, the driving record of each CMV driver it hires to determine whether that driver meets minimum requirements for safe driving or is disqualified to drive commercial motor vehicles. In reviewing the driving record, the employer must consider any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations and/or the Hazardous Materials Regulations. The employer must also consider the driver s accident record and any evidence the driver has violated laws governing the operation of motor vehicles as provided by any State driver s license bureau, and must give great weight to violations such as speeding, reckless driving, and operating while under the influence of alcohol or drugs that indicate the driver has exhibited a disregard for the safety of the public. This form and the response(s) from the state(s) which provide this driver s driving record shall be maintained in this drivers qualification file for duration of employment plus three years. TIME-OF-HIRE REVIEW I have reviewed the driving record of the above named driver in accordance with Section 391.25 of the Federal Motor Carrier Safety Regulations as outlined above, and I find: The driver meets the minimum requirements for safe driving, or The driver is disqualified to drive a commercial motor vehicle. Signature and Title of Reviewer Date PSATS CDL Program Form INITIAL QUALIFY

CMV EMPLOYEE ANNUAL REVIEW OF DRIVING RECORD Employer Name: Driver Name: Driver SSN: Federal regulation 49 CFR 391.25 requires employers to review, at least once every 12 months, the driving record of each CMV driver it employs to determine whether that driver meets minimum requirements for safe driving or is disqualified to drive commercial motor vehicles. In reviewing the driving record, the employer must consider any evidence that the driver has violated applicable provisions of the Federal Motor Carrier Safety Regulations and/or the Hazardous Materials Regulations. The employer must also consider the driver s accident record and any evidence the driver has violated laws governing the operation of motor vehicles as provided by any State driver s license bureau, and must give great weight to violations such as speeding, reckless driving, and operating while under the influence of alcohol or drugs that indicate the driver has exhibited a disregard for the safety of the public. A copy of this form, setting forth the date upon which the review was performed and the name of the person who reviewed the driving record, shall be included in each driver s qualification file. YEAR 1 I have reviewed the driving record of the above named driver in accordance with Section 391.25 of the Federal Motor Carrier Safety Regulations as outlined above, and I find: The driver meets the minimum requirements for safe driving, or The driver is disqualified to drive a commercial motor vehicle. Signature and Title of Reviewer Date YEAR 2 I have reviewed the driving record of the above named driver in accordance with Section 391.25 of the Federal Motor Carrier Safety Regulations as outlined above, and I find: The driver meets the minimum requirements for safe driving, or The driver is disqualified to drive a commercial motor vehicle. Signature and Title of Reviewer Date YEAR 3 I have reviewed the driving record of the above named driver in accordance with Section 391.25 of the Federal Motor Carrier Safety Regulations as outlined above, and I find: The driver meets the minimum requirements for safe driving, or The driver is disqualified to drive a commercial motor vehicle. Signature and Title of Reviewer Date PSATS CDL Program Form QUALIFY

Request for CMV Driver s Safety Performance History from All Employers in Past 3 Years To (name of previous employer): From (name and address of prospective employer): Driver Name: Date: Driver s License Number: The above-named individual has advised us of employment with you in a CMV capacity within the past three years. Federal regulations (49 CFR 391.23(d)) require that previous employers provide the information requested below within 30 days of receipt of this request. Once completed by you, please return this form to our address above. Failure by you to respond to this request will result in a complaint of violation being forwarded to the FMCSA. Authorization to release required information I,, hereby specifically authorize this previous employer to provide the below requested information to this new employer. Driver s signature Date Required information from previous employer 1.) Indicate dates of employment of this employee: 2.) Indicate type of work this employee did for you: 3.) Was this employee involved in any accidents as defined by 49 CFR 390.5 in the past three years? If Yes, indicate the date of accident, the municipality and state where the accident occurred, the number of injuries, the number of fatalities, and whether hazardous materials, other than fuel spilled from the fuel tanks of motor vehicle involved in the accident, were released: 4.) Is this previous employer attaching copies of any accident reports required by State or other governmental entities or insurers or as pursuant to the employer s internal policies for retaining more detailed minor accident information? Yes No Name of commentor from previous employer Commentor s Title No Investigation Possible Note: The new employer should check this box to indicate that it was not possible to obtain the aboverequested information since the applicant did not have any previous CMV employment. This form must be retained in the driver s qualification file to document why no request was made. PSATS CDL Program Form HISTORY

REQUEST FOR CDL DRUG AND ALCOHOL TESTING RESULTS FROM ALL EMPLOYERS IN PAST 3 YEARS To (name of previous employer): From (name and address of prospective employer): Driver Name: Date: Driver s License Number: The above-named individual has advised us of employment with you in a CDL capacity within the past three years. Federal CDL regulations (49 CFR 391.23(e)) require that previous employers provide the information requested below within 30 days of receipt of this request. Once completed by you, please return this form to our address above. Failure by you to respond to this request will result in a complaint of violation being forwarded to the FMCSA. Authorization to release required information I,, hereby specifically authorize this previous employer to provide the below requested information to this new employer. Driver s signature Date Required information from previous employers 1. Did this driver violate the alcohol and controlled substances prohibitions of 49 CFR Part 382 in the last three years? Yes No 2. Did this driver fail to complete a required rehabilitation program prescribed by a substance abuse professional? Yes No Unknown If Unknown, the new employer must obtain proof from the driver of successful completion of such a rehabilitation program before engaging in CMV activity. 3. If this driver had successfully completed a required rehabilitation program, and remained in the employ of this previous employer, did this driver ever: A. have another alcohol test with a result of 0.04 or higher? Yes No B. have another verified positive drug test? Yes No C. refuse any test (including verified adulterated or substitute drug test)? Yes No Name of commentor from previous employer Commentor s Title No Investigation Possible Note: The new employer should check this box to indicate that it was not possible to obtain the aboverequested information since the applicant did not have any previous CDL employment. This form must be retained in the driver s qualification file to document why no request was made. PSATS CDL Program Form RESULTS

Employee Acknowledgement of Receiving Copy of Employer s CDL Drug and Alcohol Testing Personnel Policy I hereby acknowledge that I have received a copy of this employer s drug and alcohol testing personnel policy (the Policy ) for testing the commercial driver s license employees of. (Name of Employer) I have carefully read and understand the Policy, and, without reservation, agree to follow and fully comply with the testing procedures set forth in this Policy. I understand that I may be required to submit to drug and/or alcohol tests in accordance with this Policy and that a refusal to submit to such tests within the time required will be deemed to be a positive test. I also understand that failure to comply with any provision of the said Policy is a basis for discipline in accordance with either this Policy or such other policy as adopted by the employer. Date Employee Signature Print Employee Name Note: A signed copy of this form must be permanently maintained in each CDL employee s file. PSATS CDL Program Form POLICY

PSATS CDL Program Changes to CDL Employee Roster Twp./Co. or Employer Name Contact Person Member # A copy of this form must be returned to the PSATS CDL Program as needed to maintain a current roster of your employees subject to random drug and alcohol testing. Return this form by mail to 4855 Woodland Drive, Enola, PA; by fax to (717) 763-9732; or by email to cdl@psats.org. To delete an employee, simply mark the delete box and provide employee name. If adding a new employee, include the date of the employee s negative pre-employment drug test (PEDT), or exempt if the employer has the documentation necessary to verify the employee is exempt from needing a pre-employment drug test. ( ) Add ( ) Delete ( ) Add ( ) Delete Print Employee s Name Date of PEDT or Exempt Print Employee s Name Date of PEDT or Exempt ( ) Add ( ) Delete ( ) Add ( ) Delete Print Employee s Name Date of PEDT or Exempt Print Employee s Name Date of PEDT or Exempt ( ) Add ( ) Delete ( ) Add ( ) Delete Print Employee s Name Date of PEDT or Exempt Print Employee s Name Date of PEDT or Exempt PSATS CDL Program Form ROSTER

Instructions for Completing the Form Unless noted as optional, all required information must be included on the form. Please type or print legibly in black or blue ink. This form may be duplicated. FEIN: Employer Name: Contact Name: Contact Phone Number: Employee Social Security Number: Date of Birth: Date of Hire: Employee Name: Employee Address: Federal Employer Identification Number Legal name of the employer Person authorized to answer questions on the New Hire Report (this should be someone from the employer) Phone number for the contact person The number assigned by the Social Security Administration Optional Item date of birth for the new hire The first day the new hire performs services for wages First, Middle, and Last name of the new hire Permanent address of the new hire Pennsylvania New Hire Reports may be submitted through the mail or via FAX. Mailing Address: FAX Number: Customer Service Telephone Number: Commonwealth of Pennsylvania New Hire Reporting Program PO Box 69400 Harrisburg, PA 17106-9400 717-657-HIRE 717-657-4473 1-866-748-4473 (TOLL FREE) 1-888-PAHIRES 1-888-724-4737

Required Employer Information Please mail or fax to: 1-866-748-4473 (TOLL FREE) (for questions only) Required Employee Information (Please type or print legibly in black or blue ink.) Pennsylvania New Hire Reporting Program - 5 REVISED 07/2010

Department of Homeland Security U.S. Citizenship and Immigration Services OMB No. 1615-0047; Expires 08/31/12 Form I-9, Employment Eligibility Verification Instructions Read all instructions carefully before completing this form. Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155. What Is the Purpose of This Form? The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States. When Should Form I-9 Be Used? All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9. Filling Out Form I-9 Section 1, Employee This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E- Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed. Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad. Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an employment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)). Preparer/Translator Certification The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his or her own. However, the employee must still sign Section 1 personally. Section 2, Employer For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document. If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time. Employers must record in Section 2: 1. Document title; 2. Issuing authority; 3. Document number; 4. Expiration date, if any; and 5. The date employment begins. Employers must sign and date the certification in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. Employers are still responsible for completing and retaining Form I-9. Form I-9 (Rev. 08/07/09) Y

For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information." Section 3, Updating and Reverification Employers must complete Section 3 when updating and/or reverifying Form I-9. Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in Section 1 (if any). Employers CANNOT specify which document(s) they will accept from an employee. A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A. B. If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block. C. If an employee is rehired within three years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B; and: 1. Examine any document that reflects the employee is authorized to work in the United States (see List A or C); 2. Record the document title, document number, and expiration date (if any) in Block C; and 3. Complete the signature block. Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing Section 3. What Is the Filing Fee? There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below. USCIS Forms and Information Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website at www.uscis.gov/e-verify or by calling 1-888-464-4218. General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov. Photocopying and Retaining Form I-9 A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later. Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2. Privacy Act Notice The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a). This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States. This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices. Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986. To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218. EMPLOYERS MUST RETAIN COMPLETED FORM I-9 DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS Form I-9 (Rev. 08/07/09) Y Page 2

Paperwork Reduction Act An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. Do not mail your completed Form I-9 to this address. Form I-9 (Rev. 08/07/09) Y Page 3

Department of Homeland Security U.S. Citizenship and Immigration Services OMB No. 1615-0047; Expires 08/31/12 Form I-9, Employment Eligibility Verification Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.) Print Name: Last First Middle Initial Maiden Name Address (Street Name and Number) Apt. # Date of Birth (month/day/year) City State Zip Code Social Security # I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. Employee's Signature I attest, under penalty of perjury, that I am (check one of the following): A citizen of the United States A noncitizen national of the United States (see instructions) A lawful permanent resident (Alien #) An alien authorized to work (Alien # or Admission #) until (expiration date, if applicable - month/day/year) Date (month/day/year) Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer's/Translator's Signature Print Name Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).) List A OR List B AND List C Document title: Issuing authority: Document #: Expiration Date (if any): Document #: Expiration Date (if any): CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) and that to the best of my knowledge the employee is authorized to work in the United States. (State employment agencies may omit the date the employee began employment.) Signature of Employer or Authorized Representative Print Name Title Business or Organization Name and Address (Street Name and Number, City, State, Zip Code) Date (month/day/year) Section 3. Updating and Reverification (To be completed and signed by employer.) A. New Name (if applicable) B. Date of Rehire (month/day/year) (if applicable) C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization. Document Title: Document #: Expiration Date (if any): l attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Date (month/day/year) Form I-9 (Rev. 08/07/09) Y Page 4