Jump Links
The History Records Request form plays a crucial role in the hiring process, especially for positions where safety is paramount, such as those in the transportation industry. This form is primarily utilized by prospective employees to authorize their previous employers to share vital information about their safety performance history. To ensure that all pertinent data is collected, the form is divided into several parts. The prospective employee must fill out their personal details and specify the information being requested, particularly regarding alcohol and controlled substances testing records from the last three years. This request is then directed to the prospective employer, who must comply with confidentiality regulations. Previous employers contribute to this process by providing records of the applicant’s accident history and drug and alcohol testing outcomes. The form includes specific questions that the previous employer must answer honestly, ensuring transparency about the applicant’s history. Time is of the essence; prospective employers are required to provide any received information to the applicant within five business days. This setup not only fosters accountability but also protects the interests of all parties involved in the hiring process. Understanding how to effectively navigate this form can significantly impact an applicant’s employment opportunities, making it essential for both job seekers and employers to grasp its importance fully.
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 |
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 |
||||
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 |
|
|
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
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 |
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
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
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
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
File Breakdown
| Fact | Description |
|---|---|
| Purpose | This form allows prospective employees to request safety performance history information from previous employers, ensuring transparency during the hiring process. |
| Compliance | The request is made in accordance with Department of Transportation regulations §40.25 and §391.23, ensuring proper handling of drug and alcohol testing records. |
| Submission Timelines | Prospective employers must provide requested information within five business days of receiving the request from the applicant. |
| No History Disclosure | If a previous employer has no safety performance history to report, they can indicate this on the form, noting a lack of record for the driver. |
Guide to Using History Records Request
Following these steps will ensure that you accurately complete the History Records Request form. Once filled out, this form will need to be submitted according to the specified instructions to facilitate the release of safety performance history records.
- Part 1: Prospective Employee
- Print your full name in the designated area: First, Middle Initial, and Last.
- Enter your Social Security number and Date of Birth.
- Provide the information for your Previous Employer, including Employer Name, Email, Street address, and Telephone number.
- Fill in the City, State, and Zip code for your Previous Employer.
- State your desired employment application date.
- Complete the Prospective Employer's details, such as name, address, and telephone number.
- Sign and date the section to authorize the release of your testing records.
- Submit the completed form to your Prospective Employer.
- Part 2: Previous Employer - Accident History
- Confirm employment and state job title with dates employed.
- Indicate whether the individual drove a motor vehicle for the employer.
- Specify the reason for leaving the employ.
- Complete accident details or indicate if there are none.
- Provide additional remarks if necessary and sign with title and date.
- Turn the form over to complete Part 3 on the reverse side.
- Part 3: Previous Employer - Drug and Alcohol History
- Indicate whether the driver was subject to DOT testing requirements during employment.
- Answer questions regarding the driver’s alcohol and drug test history, marking 'YES' or 'NO' as applicable.
- State the period during which the driver was subject to these requirements.
- Complete the section with your company information and signature, along with the date.
- Part 4: Prospective Employer
- Fill in the method of sending the form to the previous employer (fax, mail, etc.).
- Record the date this action was taken.
- Once received, document the source and date of the received information.
Get Answers on History Records Request
-
What is the purpose of the History Records Request form?
-
The History Records Request form is designed to help prospective employees obtain their safety performance history from previous employers. It ensures that the potential employer receives accurate information regarding the applicant's previous drug and alcohol testing records, accidents, and other relevant employment history.
-
Who fills out the form?
-
There are two main sections in the form. The first part is completed by the prospective employee, providing personal information and authorization for the previous employer to release records. The second part is filled out by the previous employer, documenting the safety performance history of the employee.
-
How can I submit the form?
-
The History Records Request form can be submitted in several ways. You can fax, email, or mail it to your previous employer. Make sure to check the appropriate box to indicate how the form was sent, as this information should be recorded by the prospective employer.
-
What information do I need to provide as a prospective employee?
-
As a prospective employee, you will need to provide:
- Your full name, including first, middle initial, and last name.
- Your Social Security number and date of birth.
- Your previous employer's information, including name, address, and contact details.
- Your signature and date of submission.
-
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 by checking the appropriate box on the form. They should then sign and return the form to the prospective employer without providing additional details.
-
How long does a prospective employer have to provide the requested information?
-
Once the prospective employer receives the written request, they must provide the requested safety performance history within five business days. If they have not yet received this information from the previous employer, the five-day period begins when they do receive it.
-
Can I review my safety performance history if I’ve been denied employment?
-
Yes, you have the right to review your safety performance history. You can request your records within the same timeframe—up to 30 days after a denial of employment. It's essential to follow the proper procedures outlined in the form to access your records.
-
What if I want to dispute information in my safety performance history?
-
If you believe there’s erroneous information in your safety performance history, you can submit a request for correction to your previous employer. They must either correct the information and forward it to the prospective employer or notify you within 15 days if they do not agree to the correction.
Common mistakes
Filling out the History Records Request form accurately is essential for every prospective employee looking to establish their safety performance history. Unfortunately, many individuals make common mistakes that can delay the process or lead to misunderstandings. One significant error is failing to complete all required fields. Incomplete forms can lead to confusion and delays, as previous employers may not know how to correctly process the request. Double-checking every section ensures that the employment and contact details are accurate and comprehensive.
Another frequent mistake involves overlooking the date of the employment application. It is critical to specify the exact date when submitting the records request. Without this date, previous employers might not be able to determine the appropriate time frame for the requested records. This could lead to unnecessary delays in processing your request. Always ensure that the date is clearly stated to streamline the information retrieval process.
People also tend to confuse their previous employers by not including sufficient contact information for both themselves and the prospective employer. When filling out the form, including accurate phone numbers and email addresses is essential. This helps facilitate communication and ensures that the required information can be promptly exchanged between the involved parties. Otherwise, the entire process can come to a halt due to a lack of communication channels.
Finally, applicants often forget to sign and date the form at the end. This final step is crucial for giving consent to release the requested records. Without a signature, the request lacks authenticity, meaning employers will not have the authority to share sensitive information. So, remember to add your signature and the date to validate your request. Taking a few extra moments to review and complete these details can make the difference in efficiently obtaining your safety performance history records.
Documents used along the form
Along with the History Records Request form, several other documents are frequently used in the process of obtaining safety performance history. Each form plays a crucial role in ensuring that both prospective employers and applicants have accurate information regarding the applicant’s history.
- Records Request for Driver/Applicant Safety Performance History: This document allows a driver or applicant to request a copy of their safety performance history from previous employers within the last three years. It is essential for reviewing any potential discrepancies prior to employment.
- Driver/Applicant Rebuttal: Should an applicant find that information in their records is inaccurate, this form enables them to formally challenge or dispute it. The rebuttal request must be sent to the previous employer to ensure that the correct information is kept on file.
- Correction Request of Erroneous Safety Performance History Information: If an applicant believes that their safety performance history contains errors, this document is used to request corrections. The previous employer must respond and either amend the records or notify the applicant of their decision.
These forms, combined with the History Records Request form, create a thorough framework for verifying safety performance history. Using the correct processes ensures transparency and compliance with Department of Transportation regulations.
Similar forms
-
Employment Verification Request: Similar to the History Records Request form, this document is designed to obtain information from previous employers regarding an applicant's employment history. Both forms require the applicant's consent for the release of information, ensuring that the information is shared in a confidential manner.
-
Background Check Authorization Form: This document seeks permission from the applicant to conduct a background check, including criminal history and credit checks. Like the History Records Request form, it emphasizes the need for informed consent and transparency in the process of obtaining sensitive information.
-
Drug and Alcohol Testing Consent Form: This form authorizes the release of any drug and alcohol test results from previous employers. It parallels the History Records Request form in its focus on the applicant's substance use history and prioritizes informed consent for the sharing of this sensitive information.
-
Release of Information Form: This document is used to grant permission for specific records or information to be shared among various parties, similar to how the History Records Request form operates. Both forms emphasize confidentiality and the importance of the applicant's authorization.
-
Personal Reference Request Form: This form is used to collect information from personal references about an applicant's character and qualifications. It shares similar elements with the History Records Request form, as each necessitates consent from the applicant for third-party engagement in the verification process.
-
Credit History Authorization Form: This document allows an employer to access an applicant's credit report. Like the History Records Request form, it is predicated on the premise of obtaining explicit permission from the applicant, further ensuring that privacy is maintained throughout the verification process.
Dos and Don'ts
- Do ensure all personal information is filled out accurately, including your name and Social Security number.
- Do sign and date the form before submitting it to your prospective employer.
- Do provide clear and complete contact information for both yourself and your previous employer.
- Do double-check the dates for your employment history to ensure accuracy.
- Don't leave any required fields blank; missing information can delay your request.
- Don't forget to authorize the release of your records; failure to do so may result in rejection.
- Don't provide misleading or false information; this could jeopardize your employment chances.
- Don't overlook the submission deadline, especially the thirty-day requirement for record retrieval.
Misconceptions
- Misconception 1: The form is only for individuals applying for truck driving positions.
- Misconception 2: Previous employers are not legally required to provide the requested information.
- Misconception 3: The prospective employee can access their safety performance history directly from past employers.
- Misconception 4: If no accidents or drug/alcohol tests are reported, that means the individual has a clean slate.
- Misconception 5: Only serious infractions will be included in my safety performance history.
- Misconception 6: The form requests only information from the last employer.
- Misconception 7: I can submit the form at any time without specific deadlines.
- Misconception 8: All information submitted on this form is confidential and cannot be shared.
This form is pertinent to anyone in the transportation sector, including those in various driving roles. It ensures a thorough check of safety performance history for all prospective employees, not just truck drivers.
Under federal regulations, previous employers must comply with the requests made on this form. They are required to provide truthful details about a driver's safety performance history, including accidents and drug or alcohol testing results.
While employees have the right to review their history, they must go through their prospective employer to obtain this information. The prospective employer serves as the intermediary in this process.
A lack of reported incidents does not automatically imply a clean record. It simply means that previous employers did not have any documentation to share concerning safety performance.
The form collects all incidents, whether minor or severe, including any that require reporting to government agencies or insurers. Complete information helps prospective employers make informed hiring decisions.
The form actually requires information from all employers within the last three years, ensuring a comprehensive overview of the applicant's driving history and safety performance.
While the request can be made at various stages, there are strict timelines outlined in the regulations. The prospective employee should arrange to pick up or receive their records within thirty days of notification to avoid waiving their request.
While the form stipulates confidentiality during the release process, the information shared may be disclosed to other prospective employers in future inquiries, especially if it relates to safety performance or regulations compliance.
Key takeaways
Complete all sections accurately with your personal information, including your full name, Social Security Number, and contact details.
Ensure you provide your consent by signing and dating the form to authorize the release of your safety performance history.
Double-check that the prospective employer’s details are filled in correctly for effective communication.
Use a secure method for sending the form, such as fax or email, to maintain confidentiality as required by law.
Previous employers must respond within a specified timeframe; plan to follow up if you don’t receive a response.
Understand that if you do not collect the requested records within 30 days, you may lose the right to review them.
The form must be completed by both the prospective employee and the previous employer—make sure each part is signed off properly.
Retain a copy of the documents for your records once the process is complete; it's critical for future reference.