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APPENDIX F-5
DRIVER SAFETY RECORD
(Contributed by Jim York, Zurich Services Corporation)
Driver Name: Terminal Name:
Incident Date and Performance Step
Calendar Year: 2004 Calendar Year: 2005
Apr.
Apr.
Nov.
Nov.
Jan.
Feb.
Mar.
Sep.
Jan.
Feb.
Mar.
Sep.
Aug.
Dec.
Aug.
Dec.
May
Jun.
Jul.
May
Jun.
Jul.
Oct.
Oct.
Safety Incident
Preventable Accident
Major Preventable Accident
Moving Violation
DOT Violation
Spill/Contamination
Other:
Notes to Terminal/Branch Managers:
1. Use this form to track the safety record of each employee during a 24 month period.
2. Enter the date and "Step Number" in the appropriate year/month box. For example, you were notified that driver John Doe's violation record indicated a speeding (Moving)
violation, which occurred on June 25, 2004. This was his first moving violation within a 24 month period. This incident would be entered in the "Moving Violation" row as
25/1 in the June, 2004 grid box.
DEFINITIONS
Preventable Accident: An accident, as ruled by the review committee, where the driver failed to do everything that reasonably could
have been done to avoid the incident
Major Preventable A preventable accident arising from a lane change, rear end collision, or intersection incident, which resulted
Accident: in a fatality, injury requiring treatment away from the scene, or disabling damage (tow away) to any vehicle(s)
Moving Violation Violations noted in driving record. Examples include: speeding, failure to obey traffic warning device/sign,
following too closely, unsafe lane change, & etc.
DOT Violations Other violations of the Federal Motor Carrier Safety Regulations. Examples include: log violation (false
logs, over hours, no/missing logs)
