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The History Records Request form is an essential document used primarily by prospective employees seeking to obtain their safety performance history from previous employers. This form is divided into several parts, each designed to gather specific information regarding the applicant's employment history, particularly related to alcohol and controlled substances testing. In the first section, the prospective employee provides personal details, including their name, Social Security number, and contact information, and authorizes the release of their testing records from the past three years to a prospective employer. Following this, previous employers are required to complete two main sections: one detailing the applicant's accident history and another focusing on their drug and alcohol testing history. Each section includes specific questions that help assess the applicant's safety performance during their previous employment. The form emphasizes confidentiality and mandates that information be shared in a secure manner, such as via fax or email. Finally, the document outlines instructions for both prospective employees and employers, ensuring that all parties understand their responsibilities in the records request process. This structured approach not only facilitates compliance with Department of Transportation regulations but also helps maintain a safe working environment in the transportation industry.

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SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PART 1:

TO BE COMPLETED BY PROSPECTIVE EMPLOYEE

I, (Print Name) ________________________________________________________ ____________________________

First

M.I.

Last

Social Security Number

Hereby authorize:

 

 

____________________

 

 

 

Date of Birth

Previous Employer: _____________________________________________________ Email: _____________________

Street: ____________________________________________________________ Telephone: _____________________

City, State, Zip: _______________________________________________________ Fax No.: _____________________

To release and forward the information requested by section 3 of this document concerning my Alcohol and Controlled Substances Testing records within the previous 3 years from ________________________________.

 

 

(employment application date)

To:

Prospective Employer: ________________________________________________________________

 

Attention:

_________________________________ Telephone: ____________________

 

Street:

________________________________________________________________

 

City, State, Zip:

________________________________________________________________

In compliance with §40.25(g) and 391.23(h), release of this information must be made in a written form that ensures confidentiality, such as fax, email, or letter.

Prospective employer’s fax number: ___________________________________

 

Prospective employer’s email address: _________________________________

 

_________________________________________________________________

____________________________

Applicant’s Signature

Date

This information is being requested in compliance with §40.25(g) and 391.23.

 

PART 2:

TO BE COMPLETED BY PREVIOUS EMPLOYER

ACCIDENT HISTORY

The applicant named above was employed by us. Yes

No

Employed as __________________________ from (m/y) ______________________ to (m/y) ______________________

1.

Did he/she drive motor vehicle for you?

Yes

No

If yes, what type?

Straight Truck

Tractor-Semitrailer

Bus

Cargo Tank

Doubles/Triples

Other (Specify) ________________________________________________

2.

Reason for leaving your employ: Discharged

Resignation

Lay Off

Military Duty

 

If there is no safety performance history to report, check here , sign below and return.

 

ACCIDENTS: Complete the following for any accidents included on your accident register (§390.15(b)) that involved the applicant in the 3 years prior to the application date shown above, or check here if there is no accident register data for this driver.

Date

Location

# Injuries

# Fatalities

Hazmat Spill

1.__________________ ___________________ __________________ __________________ __________________

2.__________________ ___________________ __________________ __________________ __________________

3.__________________ ___________________ __________________ __________________ __________________

Please provide information concerning any other accidents involving the applicant that were reported to government agencies or insurers or retained under internal company policies: _____________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________________________________

Any other remarks:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature: ____________________________________________________

Title: ______________________________ Date: ____________________

 

 

PREVIOUS EMPLOYER – COMPLETE PAGE 2 PART 3

 

 

 

 

PART 3:

TO BE COMPLETED BY PREVIOUS EMPLOYER

 

 

DRUG AND ALCOHOL HISTORY

If driver was not subject to Department of Transportation testing requirements while employed by this employer, please check here , fill in the dates of employment from _______________ to _______________, complete bottom of Part 3,

sign, and return.

Driver was subject to Department of Transportation testing requirements from _______________ to _______________.

1.

Has this person had an alcohol test with the result of 0.04 or higher alcohol concentration?

 

YES

NO

2.

Has this person tested positive or adulterated or substituted a test specimen for controlled substances?

 

YES

NO

3.

Has this person refused to submit to a post-accident, random, reasonable suspicion, or follow-up alcohol or

 

controlled substance test?

 

YES

NO

4.Has this person committed other violations of Subpart B of Part 382, or Part 40?

YES NO

5.If this person has violated a DOT drug and alcohol regulation, did this person complete a SAP-prescribed rehabilitation program in your employ, including return-to-duty and follow-up tests? If yes, please send documentation back with this form.

YES NO

6.For a driver who successfully completed a SAP’s rehabilitation referral and remained in your employ, did this

driver subsequently have an alcohol test result of 0.04 or greater, a verified positive drug test, or refuse to be tested?

YES NO

In answering these questions, include any required DOT drug or alcohol testing information obtained from prior previous employers in the previous 3 years prior to the application date shown on page 1.

Name: ___________________________________________________________________________________________

Company: ________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City, State, Zip: ____________________________________________________ Telephone: _____________________

Part 3 Completed by (Signature): ___________________________________________ Date: _____________________

PART 4a:

TO BE COMPLETED BY PROSPECTIVE EMPLOYER

This form was (check one) Faxed to previous employer Mailed Emailed Other __________________

By: __________________________________________________________________ Date: ______________________

PART 4b:

TO BE COMPLETED BY PROSPECTIVE EMPLOYER

Complete below when information is obtained.

Information received from: ____________________________________________________________________________

Recorded by: _______________________________________

Method:

Fax

Mail

Email

Telephone

Date: _____________________________________________

Other _____________________________________

INSTRUCTIONS TO COMPLETE THE SAFETY PERFORMANCE HISTORY RECORDS REQUEST

PAGE 1 PART 1: Prospective Employee

•Complete the information required in this section

•Sign and date

•Submit to the Prospective Employer

PAGE 2 PART 4a: Prospective Employer

•Complete the information

•Send to Previous Employer

PAGE 1 PART 2: Previous Employer

•Complete the information required in this section

•Sign and date

•Turn form over to complete SIDE 2 SECTION 3

PAGE 2 PART 3: Previous Employer

•Complete the information required in this section

•Sign and date

•Return to Prospective Employer

PAGE 2 PART 4b: Prospective Employer

•Record receipt of the information

•Retain the form

RECORDS REQUEST FOR

DRIVER/APPLICANT SAFETY PERFORMANCE HISTORY

This request is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(i)(2) Drivers who have previous Department of Transportation regulated employment history in the preceding three years, and wish to review previous employer-provided investigative information must submit a written request to the prospective employer, which may be done at any time, including when applying, or as late as thirty (30) days after being employed or being notified of denial of employment. The prospective employer must provide this information to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information from the previous employer(s), then the five-business-days deadline will begin when the prospective employer receives the requested safety-performance history information. If the driver has not arranged to pick up or receive the requested records within thirty (30) days of the prospective employer making them available, the prospective motor carrier may consider the driver to have waived his/her request to review the records.

PART 1:

COMPLETED BY THE DRIVER/APPLICANT

TO:

Prospective Employer: ________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ____________________________________ Telephone # _____________________

FROM:

Driver/Applicant: _____________________________ Social Security/I.D. # _____________________

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone # _____________________

I am submitting this written request to obtain copies of my Department of Transportation Safety Performance History for the preceding three years. I understand, for records requested from a prospective employer, that I must arrange to pick up or receive the requested records within thirty (30) days of the records being made available or I have waived my request to review the records.

This information should be:

sent to me at the above address.

 

 

 

 

I will arrange to pick up.

 

 

 

Driver/Applicant Signature: ___________________________________________

Date: _______/_______/_______

 

 

M

D

Y

PART 2:

COMPLETED BY THE PROSPECTIVE EMPLOYER

The information must be provided to the applicant within five (5) business days of receiving the written request. If the prospective employer has not yet received the requested information form the previous employer(s), then the five-business- days deadline will begin when the prospective employer receives the requested safety performance history information.

Information supplied to:

Name: ___________________________________________________________________________________________

Street: ____________________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________________

Comments: _______________________________________________________________________________________

__________________________________________________________________________________________________

By:

 

 

 

 

_______________________________________________

______________ Release Date: _______/_______/_______

Signature/person providing information

Telephone #

M

D

Y

COPY 1 PROSPECTIVE EMPLOYER

SAFETY PERFORMANCE HISTORY INFORMATION

DRIVER/APPLICANT REBUTTAL

This rebuttal is made by the driver/applicant in compliance with the Department of Transportation regulations.

§391.23(j)(3) Drivers wishing to rebut information in records received pursuant to paragraph (i) of this section must send the rebuttal to the previous employer with instructions to include the rebuttal in that driver’s safety performance history.

§391.23(j)(4) After October 29, 2004, within five business days of receiving a rebuttal from a driver, the previous employer must:

(i) Forward a copy of the rebuttal to the prospective motor carrier employer;

(ii)Append the rebuttal to the driver’s information in the carrier’s appropriate file, to be included as part of the response for any subsequent investigating prospective employers for the duration of the three-year data retention requirements.

PART 1:

COMPLETED BY THE DRIVER/APPLICANT

TO:

Previous Employer: ___________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ______________________________________________________________________

Telephone: ________________________________ Fax: ___________________________________

FROM:

Driver/Applicant: ____________________________________ ________________________________

Social Security #

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone No.: ___________________

I have submitted this rebuttal to my previous employer requesting that it be attached to my Safety Performance History and provided to subsequent prospective employers.

Reason for the rebuttal (attach documents as necessary): ___________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

I request that this rebuttal be sent to the attached list of motor carriers.

Driver/Applicant Signature: _____________________________________________ Date: _______/_______/_______

M D Y

PART 2:

COMPLETED BY THE PREVIOUS EMPLOYER

Received by:

Signature: ___________________________________________________________ Date: _______/_______/_______

M D Y

COPY 1 PREVIOUS EMPLOYER

CORRECTION REQUEST

OF

ERRONEOUS SAFETY PERFORMANCE HISTORY INFORMATION

This request is made by the driver/applicant in compliance with the Department of Transportation regulations, §391.23, investigations and inquiries, paragraphs (j)(1) and (2) as printed below.

§391.23(j)(1) Driver wishing to request correction of erroneous information in records received pursuant to paragraph (i) of this section must send the request for the correction to the previous employer that provided the records to the prospective employer.

§391.23(j)(2) After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier employer, or notify the driver within 15 days of receiving a driver’s request to correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the data as requested, that employer must also retain the corrected information as part of the driver’s safety performance history record and provide it to subsequent prospective employers when requests for this information are received. If the previous employer corrects the data and forwards it to the prospective motor carrier employer, there is no need to notify the driver.

PART 1:

COMPLETED BY THE DRIVER/APPLICANT

TO: Prospective Employer: ________________________________________________________________

Street/P.O. Box: _____________________________________________________________________

City, State, Zip: ____________________________________ Telephone # ______________________

FROM: Driver/Applicant: _____________________________________________________________________

Social Security/I.D. # ________________________

Street: _____________________________________________________________________________

City, State, Zip: ____________________________________ Telephone # ______________________

I request correction of erroneous information in my Safety Performance History. Please forward to the following prospective employer: Company Name: ______________________________________

Attention: ____________________________________________

Street: ______________________________________________

City, State, Zip: _______________________________________

Explanation of desired correction (attach documents as necessary)____________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Driver/Applicant Signature: ______________________________________________ Date: _______/_______/_______

M D Y

Driver: Retain COPY 4 DRIVER RECORD for your files, Submit copies 1, 2, and 3 to your previous employer.

PART 2:

COMPLETED BY THE PREVIOUS EMPLOYER

Disposition of the requested information:

Information was corrected and forwarded to the prospective motor carrier employer.

The driver was notified on _____/_____/_____ that the previous employer does not agree to correct the data.

Return copy 3 to the driver.

Information sent to: Company Name: ____________________________________

Attention: __________________________________________

Street: ____________________________________________

City, State, Zip: _____________________________________

Comments: _______________________________________________________________________________________

__________________________________________________________________________________________________

By: ________________________________________

__________________ Release Date: ______/_______/_______

Signature/person providing information

Telephone #

M

D

Y

PART 3:

COMPLETED BY THE PROSPECTIVE MOTOR CARRIER EMPLOYER

The corrected information was received on _____/_____/_____

Prospective Employer: ______________________________ Location: _______________________________________

Received by: __________________________________________

__________________________________________

Signature

Title

COPY 1 PROSPECTIVE EMPLOYER

➤ PDF File

Form Specifications

Fact Name Description
Purpose The History Records Request form is used to obtain safety performance history from previous employers.
Governing Laws This form complies with Department of Transportation regulations, specifically §40.25 and §391.23.
Time Frame The form requests records from the past three years of employment.
Confidentiality Requirement Information must be released in a manner that ensures confidentiality, such as via fax or email.
Signature Requirement The applicant must sign the form to authorize the release of their records.
Employer's Responsibilities Prospective employers must provide requested information within five business days of receipt.
Accident Reporting Employers must report any accidents involving the applicant within the last three years.
Drug and Alcohol Testing Employers must disclose any drug and alcohol test results or violations during the applicant's employment.
Rebuttal Process Applicants can submit a rebuttal to previous employers regarding any information they wish to contest.
Correction Requests Applicants can request corrections to erroneous information, which previous employers must address within 15 days.

History Records Request: Usage Guidelines

Completing the History Records Request form is an essential step for prospective employees seeking to gather their safety performance history. After filling out the form, it will be submitted to the previous employer for verification and information collection. Following this process, the prospective employer will receive the requested records and provide them to you within the stipulated timeframe.

  1. Begin with Part 1, where you will fill in your personal details. Print your full name, including your first, middle initial, and last name.
  2. Enter your Social Security Number and Date of Birth.
  3. Provide the name of your Previous Employer and their contact information, including email, street address, and telephone number.
  4. Indicate the employment application date for which you are requesting records.
  5. In the section for the Prospective Employer, fill in their name and contact information, including attention, street address, city, state, zip code, and telephone number.
  6. Specify the fax number and email address of the prospective employer for the release of information.
  7. Sign and date the form to authorize the release of your records.
  8. Hand over the completed form to your prospective employer.
  9. For the Previous Employer section, ensure they complete their part, including accident history and drug and alcohol history.
  10. Finally, the prospective employer must complete their section after receiving the information, documenting how it was received.

Your Questions, Answered

What is the History Records Request form?

The History Records Request form is a document used by prospective employees to request their safety performance history from previous employers. This form ensures that the information is shared in compliance with Department of Transportation regulations, specifically regarding alcohol and controlled substances testing records over the past three years.

Who needs to complete the form?

The form consists of several parts that must be completed by both the prospective employee and the previous employer. The prospective employee fills out the first part to authorize the release of their records. The previous employer is responsible for completing the second and third parts, which include details about the employee's accident and drug/alcohol history.

What information is required from the prospective employee?

The prospective employee must provide their name, social security number, date of birth, previous employer’s details, and contact information. Additionally, they must authorize the release of their safety performance history and sign the form to validate the request.

What does the previous employer need to provide?

The previous employer must complete sections regarding the applicant's accident history, including details of any accidents that occurred during the past three years. They must also answer questions related to the applicant's drug and alcohol testing history, including any positive tests or refusals to test.

How is the information shared?

The information must be shared in a written format that maintains confidentiality. Acceptable methods include fax, email, or postal mail. The previous employer must ensure that the prospective employer receives the completed form in a timely manner.

What happens if there is no safety performance history to report?

If the previous employer has no safety performance history to report, they must indicate this on the form and return it to the prospective employer. This acknowledgment is important for compliance with the regulations.

What is the timeline for providing the requested information?

The prospective employer must provide the requested information to the applicant within five business days of receiving the completed form from the previous employer. If the previous employer has not yet sent the information, the five-day period starts once it is received.

Can an applicant dispute information in their safety performance history?

Yes, applicants have the right to dispute any information they believe is erroneous. They can submit a rebuttal to their previous employer, who is then required to forward this rebuttal to the prospective employer and append it to the applicant's records.

What should an applicant do if they do not receive their records?

If an applicant does not arrange to pick up or receive their requested records within thirty days of them being made available, the prospective employer may consider the request waived. Therefore, it is crucial for applicants to follow up on their requests promptly.

How can an applicant ensure their records are accurate?

To ensure accuracy, applicants should carefully review their safety performance history once received. If they identify any discrepancies, they can formally request corrections from their previous employer, who must respond within a specific timeframe as outlined by the regulations.

Common mistakes

  1. Incomplete Personal Information: Many applicants forget to fill in their full name, including middle initials, which can lead to confusion in identifying the individual.

  2. Missing Social Security Number: Omitting the Social Security Number can delay the processing of the request, as this number is crucial for verification purposes.

  3. Incorrect Previous Employer Information: Providing inaccurate details about the previous employer, such as the name or address, can result in the request being sent to the wrong place.

  4. Failure to Sign and Date: Applicants often neglect to sign and date the form, which is essential for authorization and validation of the request.

  5. Not Specifying the Employment Dates: Leaving out the employment dates can cause delays, as employers need this information to locate the relevant records.

  6. Ignoring Confidentiality Requirements: Some individuals do not understand the importance of ensuring that the request is sent in a confidential manner, which is a requirement for compliance.

  7. Not Providing Contact Information: Failing to include a valid email or phone number can hinder communication between the prospective employer and the previous employer.

  8. Misunderstanding the Alcohol and Drug Testing Questions: Some applicants answer questions regarding their drug and alcohol history without fully understanding what is being asked, leading to inaccuracies.

  9. Not Checking for Additional Remarks: Leaving the section for additional remarks blank can miss an opportunity to provide important context or clarification regarding their history.

  10. Failure to Follow Submission Instructions: Not adhering to the specific submission guidelines, such as sending the form via the correct method (fax, email, or mail), can delay the processing of the request.

Documents used along the form

When navigating the process of obtaining safety performance history records, several additional forms and documents may accompany the History Records Request form. Each of these documents plays a crucial role in ensuring that both prospective employees and employers can effectively share and verify important safety-related information. Here’s a closer look at some of these forms.

  • Driver/Applicant Safety Performance History Information: This document allows drivers to formally request their safety performance history from previous employers. It ensures that drivers are aware of any records that may affect their employment opportunities, facilitating transparency in the hiring process.
  • Driver/Applicant Rebuttal: If a driver wishes to contest or clarify information in their safety performance history, this rebuttal form allows them to submit their concerns. This ensures that any discrepancies can be addressed and documented appropriately, maintaining fairness in the evaluation process.
  • Correction Request of Erroneous Safety Performance History Information: This form is used by drivers to request corrections to any inaccurate information in their safety records. By submitting this request, drivers can help ensure that their records reflect accurate data, which is vital for future employment prospects.
  • Previous Employer Accident History Report: This report provides a detailed account of any accidents involving the driver during their previous employment. It includes information about injuries, fatalities, and any hazardous materials involved, which can significantly impact a driver's employability.
  • Drug and Alcohol History Report: This document details a driver's history regarding drug and alcohol testing. It includes any positive tests or refusals, which are critical for compliance with Department of Transportation regulations and can influence hiring decisions.

Understanding these forms and their purposes can greatly assist both prospective employees and employers in ensuring a smooth and compliant hiring process. By being informed, individuals can take proactive steps to manage their safety records effectively.

Similar forms

  • Employment Verification Form: Similar to the History Records Request form, this document is used to confirm an applicant's previous employment details. It typically requires the applicant to provide personal information and authorize their former employers to share work history.
  • Background Check Authorization Form: This form allows employers to conduct a background check on potential hires. Like the History Records Request, it requires the applicant's consent and outlines what information may be accessed.
  • Drug Testing Consent Form: This document is used to obtain an applicant's permission to undergo drug testing. It parallels the History Records Request in that both forms require the applicant's signature to authorize the release of sensitive information.
  • Reference Check Authorization Form: This form allows employers to contact the applicant's personal or professional references. It shares similarities with the History Records Request by needing the applicant’s consent to gather information from third parties.
  • Wage and Salary Verification Form: This document is used to verify an applicant's salary history. It is similar to the History Records Request in that it requests detailed employment information and requires the applicant's approval for release.
  • Credit Check Authorization Form: This form allows employers to check an applicant's credit history. It is akin to the History Records Request as both require explicit consent from the applicant to access personal records.
  • Professional License Verification Form: This document is used to verify an applicant's professional licenses and certifications. Similar to the History Records Request, it necessitates the applicant’s permission to obtain information from licensing bodies.

Dos and Don'ts

When filling out the History Records Request form, there are important dos and don'ts to keep in mind. Following these guidelines can help ensure a smooth process.

  • Do fill in all required fields completely and accurately.
  • Do sign and date the form before submission.
  • Do provide your previous employer's contact information clearly.
  • Do specify the type of records you are requesting.
  • Do keep a copy of the completed form for your records.
  • Don't leave any sections blank; incomplete forms may delay processing.
  • Don't forget to include your Social Security number, as it's often required.
  • Don't submit the form without verifying that all information is correct.
  • Don't neglect to follow up with your previous employer if you do not receive a response.

Misconceptions

  • Misconception 1: The History Records Request form is only for new employees.

    • This form can also be used by current employees who wish to review their safety performance history. It is not limited to new hires.

  • Misconception 2: Only accidents need to be reported.

    • In addition to accidents, the form also requires information about drug and alcohol testing history. This is crucial for compliance with regulations.

  • Misconception 3: The applicant has no control over the information released.

    • The applicant must authorize the release of their records. This ensures that the previous employer cannot disclose information without consent.

  • Misconception 4: The form must be completed by the applicant alone.

    • Both the applicant and the previous employer must fill out sections of the form. Each party has specific responsibilities to ensure accurate reporting.

  • Misconception 5: There is no deadline for submitting the form.

    • There are specific timelines involved. The prospective employer must provide the requested information within five business days of receiving the request.

  • Misconception 6: Once submitted, the information cannot be disputed.

    • Applicants can rebut or request corrections to erroneous information. This process allows them to ensure accuracy in their records.

  • Misconception 7: The information is always available immediately.

    • There may be delays in obtaining records from previous employers. The five-business-day rule applies only after the prospective employer has received the information.

  • Misconception 8: The form is not necessary for all driving positions.

    • Any position that involves driving and falls under Department of Transportation regulations requires this form. It is essential for compliance.

  • Misconception 9: Confidentiality is not guaranteed.

    • The form includes provisions to ensure confidentiality. Information must be shared in a secure manner, such as through fax or email, to protect personal data.

Key takeaways

Key Takeaways for Filling Out and Using the History Records Request Form

  • Ensure all personal information is complete and accurate in Part 1, including your name, Social Security number, and contact details.
  • Clearly specify the prospective employer's information where the records will be sent.
  • Sign and date the form in the designated area to authorize the release of your records.
  • Understand that the form must be submitted to the prospective employer for processing.
  • Previous employers are required to respond within five business days of receiving the request.
  • Make sure to check the appropriate boxes regarding your employment history and safety performance when filling out Part 2.
  • If there are no accidents or safety performance issues to report, indicate this clearly to expedite the process.
  • Keep a copy of the completed form for your records, as it may be needed for future reference.
  • Be aware that if you do not collect the requested records within thirty days, you may waive your right to review them.