Date MM slash DD slash YYYY Job InformationApp IDJob IDThis field is hidden when viewing the formOps IDThis field is hidden when viewing the formExaminer Chosen– Fill Out Other Fields –This field is hidden when viewing the formCarrier InformationDOT #Motor Carrier NameThis field is hidden when viewing the formOps Mgr Name First Last This field is hidden when viewing the formOperations Manager Email This field is hidden when viewing the formOperations Manager– Fill Out Other Fields –This field is hidden when viewing the formJob Manager First Last This field is hidden when viewing the formJob Manager Email Examiner Name(Required) First Last Examiner Email This field is hidden when viewing the formMx2aThis field is hidden when viewing the formMx3aApplicant InformationApplicant Name First Last Preferred NameThis field is hidden when viewing the formApplicant Email This field is hidden when viewing the formCatchall Email LicensingLast 4 of CDL(Required)Licensing StateLicense ClassCDL Exp Date(Required) MM slash DD slash YYYY Road Test DetailsStart Time(Required) Hours : Minutes End Time(Required) Hours : Minutes Weather Conditions(Required)— Select —ClearOvercastRainSnowIceMiles Driven(Required)Vehicle Type(Required)— Select —Tractor TrailerBox TruckBoom TruckBusCar CarrierDump TruckFire TruckFuel TruckGarbage TruckMixerPlow TruckService TruckTank TruckTow TruckWater TruckWreckerTrailer Type(Required)— Select —FlatbedDry VanTankerConestogaReeferEnd DumpSide DumpRoll-offDoublesTriplesGooseneckIntermodalBelly DumpLow-BoyPassengerSchool BusPneumaticSpecializedWalking FloorCar HaulerStraight TruckLocation If passenger carrier, type of busPre-Trip InspectionChecked Lights, Tires, & FluidsYesNoN/AVerified Logs & DocumentsYesNoN/AHow long was the Pre-Trip?20 Min15 Min10 Min5 MinNonePre-Trip ScorePassNeeds ImprovementFailWas Post-Trip conducted?YesNoN/AHow long was the post-trip?15 Min10 Min5 Min3 MinNoneComments on Inspections (Optional)Driving Skills AssessmentStartsExcellentGoodFairPoorN/AStopsExcellentGoodFairPoorN/ALeft TurnsExcellentGoodFairPoorN/ARight TurnsExcellentGoodFairPoorN/ALane ControlExcellentGoodFairPoorN/AMirror UsageExcellentGoodFairPoorN/ASpeed ControlExcellentGoodFairPoorN/AFollowing DistanceExcellentGoodFairPoorN/AUse of SignalsExcellentGoodFairPoorN/ADefensive Driving AwarenessExcellentGoodFairPoorN/ARailroad Crossing ProtocolExcellentGoodFairPoorN/ABacking Maneuver (Dock)ExcellentGoodFairPoorN/ABacking Maneuver (Straight Line)ExcellentGoodFairPoorN/ABacking Maneuver (Blind)ExcellentGoodFairPoorN/AParking ProcedureExcellentGoodFairPoorN/AOverall Vehicle ControlExcellentGoodFairPoorN/AComments on Driving Skills (Optional)Safety & ComplianceSeatbelt UsageYesNoN/ACellphone UsageNoYesN/ATraffic Violations during TestNoYesN/ASafety ScorePassNeeds ImprovementFailComments on Safety (Optional)OverallDriver's degree of competency(Required) Excellent Good Fair Poor Do you recommend this driver?(Required) Strongly Recommend Recommend Neutral / Hold for Further Review Do Not Recommend Areas for Improvement (Optional)General Comments (Optional)CertificationINSTRUCTIONS: If the road test is successfully completed, the person who gave it shall complete a certificate of the driver’s road test. The original or copy of the certificate shall be retained in the employing motor carrier’s driver qualification file of the person examined and a copy given to the person who was examined. (49 CFR 391.31(e)(f)(g)) Certification This is to certify that the above-named driver was given a road test under my supervision. It is my considered opinion that this driver possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above. Date of Road Test MM slash DD slash YYYY Road Test Miles DrivenRoad Test Length (Hours)Examiner's NameSignature
