Attachment G - Draft Experienced Driver Information Form

O MB Control Number: TBD

Expiration Date: TBD

SAFE DRIVER APPRENTICESHIP PILOT PROGRAM

EXPERIENCED DRIVER INFORMATION FORM

This form collects information on drivers who are anticipating serving as an experienced driver for a motor carrier who has been approved to participate in the Federal Motor Carrier Safety Administration’s (FMCSA) Safe Driver Apprenticeship Pilot Program. Experienced drivers will have their qualifications reviewed to ensure they meet the requirements laid out in Section 23022 of the Infrastructure Investment and Jobs Act (IIJA). Determination of eligibility will be sent to the applicable motor carrier within XX days of receipt of this application.
DRIVER INFORMATION
NAME (Last, First, Middle)	GENDER	DATE OF BIRTH (mm/dd/yyyy)	CDL NUMBER	STATE OF ISSUANCE

EMPLOYMENT HISTORY (MUST COVER AT LEAST THE PAST TWO YEARS)
CURRENT EMPLOYER (CARRIER NAME)	CARRIER’S USDOT NUMBER	START DATE	POINT OF CONTACT (Name and phone number, or e-mail address)
PREVIOUS EMPLOYER (CARRIER NAME)	CARRIER’S USDOT NUMBER	DATES OF EMPLOYMENT (mm/dd/yyyy – mm/dd/yyyy)	POINT OF CONTACT (Name and phone number, or e-mail address)
PREVIOUS EMPLOYER (CARRIER NAME)	CARRIER’S USDOT NUMBER	DATES OF EMPLOYMENT (mm/dd/yyyy – mm/dd/yyyy)	POINT OF CONTACT (Name and phone number, or e-mail address)
PREVIOUS EMPLOYER (CARRIER NAME)	CARRIER’S USDOT NUMBER	DATES OF EMPLOYMENT (mm/dd/yyyy – mm/dd/yyyy)	POINT OF CONTACT (Name and phone number, or e-mail address)

DRIVING EXPERIENCE AND QUALIFICATIONS
When did you acquire your CDL (mm/dd/yyyy)? ________________ How many years of experience do you have driving a commercial motor vehicle? ______________ years In the previous two years have you had any preventable, DOT reportable accidents? ☐Yes ☐No In the previous two years, have you had any pointed moving violations? ☐Yes ☐No Are you currently operating under any exemptions from FMCSA Regulations? ☐Yes ☐No If yes, please provide a brief description of the exemption(S): ☐By checking this box, you acknowledge that the information provided is accurate to the best of your knowledge and that you meet the requirements to serve as an experienced driver to an apprentice.
SIGNATURE _____________________________________________ DATE (mm/dd/yyyy) ________________

Disclaimer

This information is being conducted for research purposes only. No identifying information will be publicly disseminated. Also, this information will not be utilized to implement any enforcement or regulatory action. However, as a heavy vehicle driver you are subject to all FMCSA rules and regulations. FMCSA may remove a driver from the pilot or cancel the pilot at any time.

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is TBD. Public reporting for this collection of information is estimated to be approximately 20 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

Privacy Statement

• Authority: 49 CFR 381.400; Infrastructure Investment and Jobs Act, Section 23022

• Purpose: FMCSA will be collecting this data for use in the research effort title “Safe Driver Apprenticeship Pilot Program”. Additionally, this data may be used for future undetermined research efforts, but cannot be used for enforcement purposes.

• Routine Uses: In addition to those disclosures permitted under 5 USC 552a(b) of the Privacy Act of 1974, additional disclosures may be made in accordance with the U.S. Department of Transportation (DOT) Prefatory Statement of General Routine Uses published in the Federal Register on December 29, 2010 (75 FR 82132), under ‘‘Prefatory Statement of General Routine Uses’’ (available at http://www.dot.gov/privacy/privacyactnotices).

• Disclosure: The disclosure of this data is voluntary, however, failure to provide the requested information may result in dismissal from participating in the pilot program. For drivers granted privilege to operate under an exemption through this program, dismissal from the pilot program will result in the denial to continue operating under that exemption.