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Fill Out Your History Records Request Form

The Safety Performance History Records Request form is a document used by prospective employees to authorize the release of their safety performance history from previous employers. This history includes records related to alcohol and controlled substance testing over the last three years. Proper completion of this form ensures compliance with Department of Transportation regulations and facilitates a thorough review of an applicant's background.

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Article Structure

The Safety Performance History Records Request form plays a critical role in the employment process for drivers, particularly those seeking positions regulated by the Department of Transportation (DOT). This form is divided into several parts designated for both the prospective employee and their previous employer. In the first section, the prospective employee must fill in personal details, grant authorization for the release of specific records, and ensure the information reaches the prospective employer. The prospective employer then has responsibilities that include sending the request to the previous employer and recording the methods of communication used. The previous employer must respond with details about the applicant's safety performance history, including accident records and alcohol and drug testing results, spanning the previous three years. Should any discrepancies arise, provisions for rebuttals and requests for corrections are included in the subsequent parts of the form. Ensuring privacy and adherence to regulatory requirements is paramount, making this form essential for a transparent hiring process that protects both employers and employees alike.

History Records Request Example

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

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

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

Get History Records Request PDF Form

Form Characteristics

Fact Name	Details
Purpose	The History Records Request form facilitates the applicant's request for their safety performance history related to drug and alcohol testing.
Applicable Laws	The form is governed by the Department of Transportation (DOT) regulations, specifically §40.25 and §391.23.
Historical Context	The requirement for this form was established to ensure transparency and accountability in driver safety records.
Completion Requirement	Part 1 of the form must be filled out by the prospective employee to authorize the previous employer to release their records.
Employer's Role	The previous employer must disclose any safety performance records within five business days of receiving the written request.
Retention Policy	Records must be kept for three years and include safety performance history for any incidents reported.
Confidentiality	According to §40.25(g), the release of information must be conducted in a manner that ensures confidentiality.
Consequences of Inaction	If the applicant does not arrange to receive their records within 30 days, they may be considered to have waived their request.
Accident Reporting	Previous employers are required to report specific details about accidents involving the applicant from the past three years.
Right to Rebuttal	Applicants can dispute any negative findings by submitting a rebuttal to their previous employer in compliance with §391.23(j)(3).

Guidelines on Utilizing History Records Request

After you have gathered the necessary information, it's time to complete the History Records Request form. This form is essential for ensuring accurate safety performance history is recorded and shared appropriately. Careful completion will help facilitate the process with your previous employer and provide your prospective employer the information they need.

Part 1 - Prospective Employee Information: Start by filling in your full name, including your first name, middle initial, and last name.
Provide your Social Security Number and Date of Birth. Be sure these details are correct, as they are critical for identification purposes.
Fill in the name of your previous employer and their contact details: email, street address, telephone, city, state, and zip code.
Next, enter the date of the employment application in the designated space.
Clearly write the name of the prospective employer, along with their contact information, similar to what you provided for the previous employer.
Complete the fax number and email address for your prospective employer.
Sign and date the form at the bottom of Part 1 to confirm your authorization for the release of your records.
Make sure to keep a copy of the completed form for your records.

Once you have completed Part 1, it's time for the previous employer to take over with Part 2 and Part 3, where they provide specific safety and alcohol testing information. After they complete it, they will return it to the prospective employer. You should follow up to ensure that the process continues smoothly.

What You Should Know About This Form

What is the purpose of the History Records Request form?

The History Records Request form is designed to gather information about a driver's safety performance and drug and alcohol testing history from previous employers. This ensures compliance with Department of Transportation regulations and helps prospective employers make informed hiring decisions.

Who should complete Part 1 of the form?

Part 1 should be completed by the prospective employee, or the driver who is seeking employment. The driver must provide personal information, including their name, social security number, date of birth, and previous employer details. This section requires the driver's signature, authorizing the release of their safety performance records.

What information is included in Part 2 of the form?

Part 2 is intended for the previous employer to fill out. This section covers the applicant's accident history and employment details. Employers must indicate whether the applicant drove a motor vehicle, the reason for their departure, and provide details of any accidents within the past three years. If there are no accidents to report, this must be noted as well.

What types of accidents need to be reported by the previous employer?

Employers must report any accidents involving the applicant that occurred within the three years prior to the application date. They should include information about the date of the accident, location, number of injuries, fatalities, and if there was a hazardous materials spill. Employers should also provide details on other incidents reported to government agencies or insurers.

In Part 3, what information related to drug and alcohol history is the previous employer required to provide?

Part 3 requires the previous employer to disclose if the driver had any alcohol tests yielding a result of 0.04 or higher. It also asks whether the applicant tested positive for controlled substances, refused to submit to testing, or committed other violations related to drug and alcohol policies. This section helps ensure that the prospective employer is aware of any relevant history that could impact the driver's eligibility.

What is the significance of the 30-day timeline mentioned in the form?

The 30-day timeline indicates that the driver must arrange to receive or pick up the requested records within 30 days of them being made available by the prospective employer. If this does not happen, the driver waives their right to review those records. This encourages timely communication and ensures the process remains efficient.

What actions must a previous employer take after receiving a rebuttal from a driver?

If a driver wishes to dispute information in their records, they can submit a rebuttal. The previous employer must forward this rebuttal to the prospective motor carrier and append it to the driver's information in their records within five business days.

What should a driver do if they find erroneous information in their safety performance records?

If a driver identifies erroneous information, they should complete a correction request and submit it to the previous employer. The employer must either correct the information and forward it to the prospective employer or notify the driver if they do not agree to the correction.

What is the time frame for a prospective employer to provide information to the driver?

A prospective employer must provide the requested safety performance history to the driver within five business days of receiving the written request. If they are still waiting on records from previous employers, this five-day countdown begins once they receive the required information.

Common mistakes

Completing the History Records Request form may seem straightforward, but many individuals inadvertently make significant mistakes that can delay or complicate the process. One common error occurs when applicants neglect to provide their full legal name in the designated area. It is crucial to print the name clearly, including first, middle initial, and last name, to avoid mismatches with records held by previous employers.

Another frequent mistake is the omission or incorrect entry of the Social Security Number. This piece of information is vital for accurately locating the applicant's records. Without it, there is a risk that past employers may not find the necessary information, potentially leading to delays in hiring.

Applicants often fail to specify the correct prospective employer details in the form. The section requesting the employer’s name, address, and contact information must be filled out completely. If the prospective employer is not correctly identified, the request may be misdirected, leading to further complications.

A lack of attention to the employment application date is another common oversight. The date must accurately reflect the time frame for which the safety performance records are being requested. If left blank or filled in incorrectly, it undermines the purpose of the request and may hinder the retrieval of specific records.

Additionally, the designated method of information release is frequently mismanaged. Applicants must ensure that they provide the email address and fax number of their prospective employer accurately. Errors in these contact details can cause potential employers to miss the information they need to evaluate the applicant effectively.

Finally, signatures must be clear and properly dated at the end of the form. A missing or incorrectly dated signature can render the entire request invalid, which means applicants must pay careful attention when finalizing their request to ensure it is processed in a timely manner.

Documents used along the form

The History Records Request form is a crucial document utilized during the hiring process, particularly in the transportation industry. When seeking a driver's safety performance history, several other documents are frequently used in conjunction. Each of these forms serves a specific purpose in confirming the accuracy of an applicant’s past employment and compliance with Department of Transportation regulations.

Authorization for Release of Information: This document allows previous employers to share the applicant's records with prospective employers. It secures consent from the applicant, ensuring that there are no violations of privacy laws.
Employment Verification Form: This form is completed by previous employers to confirm a candidate's job history. It includes details about the dates of employment, job title, and the nature of the applicant’s departure.
Accident History Report: This document itemizes any accidents involving the applicant while in previous employment. It should include dates, locations, and any injuries incurred during these incidents.
Drug and Alcohol Testing History: Employers are required to track the applicant's drug and alcohol testing history. This form contains questions about prior positive tests and participation in rehabilitation programs.
Rebuttal of Safety Performance History: Should a driver wish to dispute information in their records, this form is used to request corrections or provide additional context. It's an important document for maintaining accurate records.
Request for Correction of Erroneous Safety Performance History: This form is used by applicants to formally ask previous employers to correct mistakes in the safety performance history that may impact future employment opportunities.
Driver’s Privacy Notice: This notice informs applicants of their rights concerning their safety performance history. It clarifies the nature of the information being shared and the process involved in handling their records.
Confirmation of Receipt: Upon receiving the requested records from a previous employer, this document confirms that the prospective employer has reviewed the information and indicates the next steps in the hiring process.

These forms work together to create a comprehensive picture of an applicant's safety record, drug and alcohol testing history, and overall employment background. Collectively, they ensure that both the applicant and the prospective employer are well-informed and protected throughout the hiring process.

Similar forms

Employment Verification Form: Similar to the History Records Request form, this document also requires personal details from the employee, such as their name, Social Security number, and previous employer information. Both forms aim to verify a candidate's employment history, though the Employment Verification form may not include specific safety performance records.
Background Check Authorization Form: This form is used to authorize a third party to conduct a background check on a prospective employee. Like the History Records Request form, it mandates that personal identifying information be provided and ensures compliance with legal requirements relating to confidentiality.
Release of Information Form: This form is often utilized in various industries to obtain consent from an individual to access their records or information from previous employers. It shares the same fundamental element of requesting confirmation for the release of specified data, including safety and performance records.
Drug Testing Consent Form: This form is focused on obtaining consent from employees for drug tests during employment. The safety performance history request is similar as it also deals with drug and alcohol testing history, ensuring compliance with occupational safety regulations.
Motor Vehicle Record (MVR) Request: Similar to the History Records Request form, this document collects personal information to obtain a driver's records from state agencies. Both documents serve to assess an individual's qualifications, with a specific focus on their driving history and safety performance.
Safety Performance Report: This document provides a summary of an employee’s safety record within a given timeframe, often aligning with the three-year period stated in the history records request. Both highlight critical safety and performance metrics that are vital for hiring decisions in safety-sensitive positions.
Reference Check Form: This form is used to gather feedback about a prospective employee’s previous work performance and behavior from former supervisors or colleagues. Like the History Records Request form, it seeks insights that can influence hiring decisions, though it may focus more on qualitative assessments rather than statistical records.

Dos and Don'ts

Things to Do When Filling Out the History Records Request Form:

Provide all required personal information accurately.
Sign and date the form before submission.
Clearly indicate the prospective employer's contact details.
Double-check the request for completeness and accuracy.
Keep a copy of the completed form for your records.

Things Not to Do When Filling Out the History Records Request Form:

Do not leave any required fields blank.
Do not submit the form without a signature and date.
Do not use a personal email for requests if a professional one is available.
Avoid vague language; be specific in your requests.
Do not forget to follow up if you do not receive a response within a reasonable timeframe.

Misconceptions

Misconceptions surrounding the Safety Performance History Records Request form can create confusion and hinder the application process. Here are ten common myths, along with clear explanations to clarify the truth.

Myth 1: The form is only necessary for truck drivers.

This form is required for all drivers who have regulated employment history under the Department of Transportation, not just truck drivers. Any job that involves operating a commercial vehicle may necessitate this form.

Myth 2: Previous employers can deny the records request without reason.

Under regulations, previous employers must provide the requested information within five business days, unless they have not yet received the data or the request is incomplete.

Myth 3: The consent form is optional.

Consent from the prospective employee is mandatory. Without this authorization, previous employers cannot legally release the requested safety performance history.

Myth 4: Information provided by previous employers is always accurate.

While employers strive to provide accurate data, errors can occur. If discrepancies arise, drivers can correct erroneous information by submitting a formal request.

Myth 5: Drivers can only review their records once.

Drivers have the right to request to review their safety performance history at any time within three years of employing with a new company. This can be done even after employment has commenced.

Myth 6: The form must be submitted in person.

The request can be submitted through various methods including mail, fax, or email, as long as proper instructions are followed and consent is given.

Myth 7: Only accidents are reported on the form.

Besides accidents, the form also collects data on any substance abuse violations or failures to comply with testing requirements. This comprehensive information provides a complete picture of the driver's history.

Myth 8: The prospective employer must wait for all records to be received before taking action.

The prospective employer has five business days to act upon the request. If they have received the required safety performance history, they must share it with the driver regardless of any pending information from other employers.

Myth 9: If no issues are reported, the request is not necessary.

Even if no issues exist in the records, submitting the request ensures that drivers can review their history. It serves as a safeguard against any potential inaccuracies that may not have been previously addressed.

Myth 10: Failure to request records means the driver has waived their rights.

While drivers must arrange to review their records within 30 days, they are entitled to request them at any point within three years. A failure to act does not constitute a permanent waiver of their rights.

Key takeaways

Key Takeaways for Completing the History Records Request Form

The form has four main parts, each focusing on specific information needed from the prospective employee, previous employer, and prospective employer.
Part 1 requires the prospective employee to fill in personal details, including name, social security number, and contact information.
The employee authorizes the release of their alcohol and controlled substances testing records for the past three years.
Employers must submit the requested information in a confidential manner, such as email or fax, as specified by regulations.
Part 2 is for previous employers to report on the applicant’s employment history, accidents, and reason for leaving the job.
In the event of accidents, employers need to provide detailed information, including location, injuries, and fatalities involved.
Part 3 focuses on the applicant's drug and alcohol testing history during their employment, asking specific questions about test results.
Prospective employers must provide requested information to applicants within five business days of receiving the form.
It’s important for applicants to arrange to pick up their records or request delivery within thirty days to avoid waiving their rights.
Rebuttals or corrections to any erroneous safety performance data must also follow specific procedures and should be sent to previous employers.

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