Information

  • Document No.

  • Legal Name

  • Trade Name

  • USDOT #

  • Conducted on

  • Address
  • Assessor

Part A

COMPANY OPERATION

  • (Mark all that apply)

OPERATION CLASSIFICATION

  • (Mark all that apply)

  • Other

HAZARDOUS MATERIALS

  • Do you transport hazardous materials?

  • List all Hazardous Materials Transported

  • Do you transport placardable quantities of HM?

  • Is an HM permit required?

  • Enter HM permit number here

COMMODITIES

  • List all commodities transported

  • Other

DRIVER INFORMATION

  • Interstate Drivers (Previous 365 Days)

  • Intrastate Drivers (Previous 365 Days)

  • Total CDL Drivers

  • Total Non-CDL Drivers

STRAIGHT TRUCKS

  • Do you operate any straight trucks?

  • Do you own any straight trucks?

  • Total

  • Do you term lease any straight trucks?

  • Total

  • Do you have any trip leased straight trucks?

  • Total

TRUCK TRACTORS

  • Do you operate any truck tractors?

  • Do you own any truck tractors?

  • Total

  • Do you term lease any truck tractors?

  • Total

  • Do you trip lease any truck tractors?

  • Total

TRAILERS

  • Do you utilize any trailers?

  • Do you own any trailers?

  • Total

  • Do you term lease any trailers?

  • Total

  • Do you trip lease any trailers?

  • Total

HAZMAT CARGO TANK TRUCKS

  • Do you operate any HM cargo tank trucks?

  • Do you own any HM cargo tank trucks?

  • Total

  • Do you term lease any HM cargo tank trucks?

  • Total

  • Do you trip lease any HM cargo tank trucks?

  • Total

HAZMAT CARGO TANK TRAILERS

  • Do you utilize any cargo tank trailers?

  • Do you own any HM cargo tank trailers?

  • Total

  • Do you term lease any HM cargo tank trailers?

  • Total

  • Do you trip lease any HM cargo tank trailers?

  • Total

MOTORCOACH

  • Do you operate any motorcoaches?

  • Do you own any motorcoaches?

  • Total

  • Do you term lease any motorcoaches?

  • Total

  • Do you trip lease any motorcoaches?

  • Total

SCHOOL BUS

  • Do you operate any school buses?

  • Do you own any school buses?

  • Total

  • Do you term lease any buses?

  • Total

  • Do you trip lease any buses?

  • Total

MINI-BUS

  • Do you operate any mini-buses?

  • Do you own any mini-buses?

  • Total

  • Do you term lease any mini-buses?

  • Total

  • Do you trip lease any mini-buses?

  • Total

PASSENGER VAN

  • Do you operate any passenger vans?

  • Do you own any passenger vans?

  • Total

  • Do you term lease any passenger vans?

  • Total

  • Do you trip lease any passenger vans?

  • Total

LIMOUSINE

  • Do you operate any limousines?

  • Do you own any limousines?

  • Total

  • Do you term lease any limousines?

  • Total

  • Do you trip lease any limousines?

  • Total

TOTAL MILES DRIVEN FOR PREVIOUS YEAR

  • Mileage

TOTAL INSPECTIONS (Roadside / Terminal)

  • Have you had any roadside or terminal inspections within the previous 365 days?

  • Total

  • Were any inspections out-of-service?

  • Total

RECORDABLE ACCIDENTS (Fatalities, Injuries Requiring Immediate Medical Treatment, Towed Vehicles)

  • Have you had any recordable accidents in the previous 3 years?

  • List all recordable accidents.

LOCATION OF REVIEW

  • Where was the review conducted?

  • Other Location

IFTA / IRP

  • Have you filed for IFTA / IRP registration?

  • Date Completed

UCR

  • Have you filed your UCR registration?

  • Date Completed

MCS-150 UPDATE / CHANGES

  • Have you completed your MCS-150 application / update / changes?

  • Date Completed

INTERSTATE FOR-HIRE AUTHORITY (if applicable)

  • Have you applied for your interstate for-hire authority?

  • Enter Interstate (MC) Authority information

INTRASTATE FOR-HIRE AUTHORITY (If applicable)

  • Have you applied for your intrastate for-hire authority?

  • Enter Intrastate Authority information (if applicable)

Part B

GENERAL

  • General #1 Section # 387.7(a) - Acute<br>Does the carrier have the required minimum level of financial responsibility in effect (property carrier)?

  • General # 2 Section # 387.7(d) - Critical<br>Does the carrier have required proof of financial responsibility (property carrier)?

  • General # 3 Section # 387.31(a) - Acute<br>Does the carrier have the required minimum level of financial responsibility in effect (passenger carrier)?

  • General # 4 Section # 387.31(d) - Critical<br>Does the carrier have the required proof of financial responsibility (passenger carrier)?

  • General # 5 Section 13901 (392.9a(a)(1))<br>Is the motor carrier authorized to conduct interstate operations in the United States?

  • General # 6 Section # 390.15(b)(1)<br>Can the carrier provide a complete accident register of recordable accidents?

  • General # 7 Section # 390.15(b)(2) - Critical<br>Does the carrier have copies of all accident reports required by States or other government entities or insurers?

  • General # 8 Section # 390.3(e)<br>Is the carrier knowledgeable of the FMCSRs/HMRs?

  • General # 9 Section # 390.21<br>Does the carrier know the commercial motor vehicles marking requirements?

DRIVER

  • Driver # 1 Section # 391.51(a) - Critical<br>Does the carrier maintain driver qualification files?

  • Driver # 2 Section # 391.11(b)(4) - Acute<br>Is the carrier using physically qualified drivers?

  • Driver # 3 Section # 391.45(a), 391.45(b) - Critical<br>Is the carrier using a driver without a medical certificate or with an expired medical certificate?

  • Driver # 4 Section # 391.15(a) - Acute<br>Is the carrier using any disqualified drivers?

  • Driver # 5 Section # 391.51(b)(2) - Critical<br>Does the carrier maintain driving inquiry data in driver qualification files?

COMMERCIAL DRIVERS LICENSE (CDL)

  • Are any drivers required to have a CDL?

  • Driver # 6 Section # 382.115(a), 382.115(b) - Acute<br>Has the carrier implemented an alcohol and/or controlled substances testing program?

  • Driver # 7 Section # 382.213(b) - Acute<br>Has the carrier used drivers who have used controlled substances?

  • Driver # 8 Section # 382.215 - Acute<br>Has the carrier used a driver who has tested positive for a controlled substance?

  • Driver # 9 Section # 382.301 - Acute<br>Has the carrier used a driver known to have an alcohol concentration of 0.04 or greater?

  • Driver # 10 Section # 382.505(a) - Acute<br>Has the carrier used a driver found to have an alcohol concentration of 0.02 or greater but less than 0.04 within 24 hours of being tested?

  • Driver # 11 Section # 382.301(a) - Critical<br>Has the carrier ensured that drivers have undergone testing for controlled substances prior to performing a safety sensitive function?

  • Driver # 12 Section # 382.303(a) - Critical<br>Has the carrier conducted post accident testing on driver for alcohol?

  • Driver # 13 Section # 382.303(b) - Critical<br>Has the carrier conducted post accident testing on drivers for controlled substances?

  • Driver # 14 Section 382.305 - Acute<br>Has the carrier implemented a random testing program?

  • Driver # 15 Section 382.305(b)(1) - Critical<br>Has the carrier conducted random alcohol testing at an annual rate of not less than the applicable annual rate or prorated rate of the average number of driver positions?

  • Driver # 16 Section # 382.305(b)(2) - Critical<br>Has the carrier conducted controlled substance testing at the applicable prorated rate of not less than the applicable annual rate of the average number of driver positions?

  • Driver # 17 Section # 40.305(a)<br>Has the carrier conducted the required return-to-duty tests on employees returning to safety-sensitive functions?

  • Driver # 18 Section # 40.309(a)<br>Is the carrier conducting follow-up testing as directed by the Substance Abuse Professional?

  • Driver # 19 Section # 382.211 - Acute<br>Has the carrier used a driver who has refused to submit to an alcohol or controlled substances test required under Part 382?

  • Driver # 20 Section # 382.503 - Critical<br>Has the carrier used a Substance Abuse Professional as required by 49 CFR Part 40 Subpart O?

  • Driver # 21 Section # 383.23(a) - Critical<br>Has a driver operated a commercial motor vehicle without a current operating license, or a license, which hasn't been properly classed and endorsed?

  • Driver # 22 Section # 383.37(a) - Acute<br>Has the motor carrier knowingly allowed its drivers whose CDLs have been suspended, revoked or canceled by a state, have lost the right to operate a CMV in a state, or have been disqualified from operating a CMV to operate a commercial motor vehicle?

  • Driver # 23 Section # 383.51(a) - Acute<br>Has the motor carrier knowingly allowed, required, permitted, or authorized a driver to drive who is disqualified to drive a commercial motor vehicle?

OPERATIONS

  • Do any drivers utilize a time sheet to record hours of service?

  • Operations # 1 Section # 395.1(e)(1), 395.1(e)(2)<br>Does the carrier have a system for recording hours of duty status on 100/150 air-mile radius drivers, and are they properly utilizing the 100/150 air-mile radius exemption?

  • Operations # 2 Section # 395.8(a) - Critical<br>Does the carrier require drivers to make a record of duty status?

  • Operations # 3 Section # 395.8(i) - Critical<br>Does the carrier require drivers to submit records of duty status within 13 days?

  • Operations # 4 Section # 395.8(k)(1) - Critical<br>Can the carrier produce records of duty status and supporting documents for selected drivers?

  • Operations # 5 Section # 395.3(a)(1) - Critical<br>Has the carrier allowed driver(s) to exceed the 11-hour rule? (Property)

  • Operations # 6 Section # 395.3(a)(2) - Critical<br>Has the carrier allowed driver(s) to exceed the 14-hour rule? (Property)

  • Operations # 7 Section # 395.3(b)(1) - Critical<br>Has the carrier allowed driver(s) to drive after having been on duty more than 60 hours in 7 consecutive days? (Property)

  • Operations # 8 Section # 395.3(b)(2) - Critical<br>Has the carrier allowed driver(s) to drive after having been on duty more than 70 hours in 8 consecutive days? (Property)

  • Operations # 9 Section # 395.5(a)(1) - Critical<br>Has the carrier allowed driver(s) to exceed the 10-hour rule? (Passenger)

  • Operations # 10 Section # 395.5(a)(2) - Critical<br>Has the carrier allowed driver(s) to exceed the 15-hour rule? (Passenger)

  • Operations # 11 Section # 395.5(b)(1) - Critical<br>Has the carrier allowed driver(s) to driver after having been on duty more than 60 hours in 7 consecutive days? (Passenger)

  • Operations # 12 Section # 395.5(b)(2) - Critical<br>Has the carrier allowed driver(s) to driver after having been on duty more than 70 hours in 8 consecutive days? (Passenger)

  • Operations # 13 Section # 395.8(e) - Critical<br>Does available evidence indicate a selected driver has prepared a false record of duty status?

  • Operations # 14 Section # 392.2 - Critical<br>Does the motor carrier ensure that drivers operate commercial motor vehicles in accordance with the laws, ordinances, and regulations of the jurisdictions in which they are operating?

  • Operation # 15 Section # 392.9(a)(1) - Critical<br>Does the carrier ensure that drivers are not permitted to drive a vehicle without the cargo properly distributed and adequately secured?

  • Operations # 16 Section # 392.4(b) - Acute<br>Have any drivers operated a commercial motor vehicle while under the influence of, or in possession of, narcotic drugs, amphetamines, or any other substances capable of rendering the drivers incapable of safely operating motor vehicles?

  • Operations # 17 Section # 392.5(b)(1) - Acute<br>Have any drivers operated a commercial motor vehicle while under the influence of, or in possession of, intoxicating beverages?

  • Operations # 18 Section # 392.5(b)(2) - Acute<br>Have any drivers operated a commercial motor vehicle within 4 hours of having consumed intoxicating beverages?

MAINTENANCE

  • Maintenance # 1 Section # 396.3(b) - Critical<br>Can the carrier produce maintenance files for requested vehicle(s)?

  • Maintenance # 2 Section # 396.17(a) - Critical<br>Can the carrier produce evidence of periodic (annual) inspections for selected vehicles?

  • Maintenance # 3 Section # 396.11(a) - Critical<br>Does the motor carrier require drivers to complete vehicle inspection reports daily?

  • Maintenance # 4 Section # 396.11(c) - Acute<br>Does the carrier ensure that out-of-service defects listed by the driver in the driver vehicle inspection reports are corrected before the vehicle is operated again?

  • Maintenance # 5 Section # 396.9(c)(2) - Acute<br>Does the carrier ensure vehicles that have been declared "out-of-service" do not operate before repairs have been made?

  • Maintenance # 6 Section 396.19<br>Is the carrier using qualified inspections (mechanic) and maintaining evidence of the inspector's qualifications?

  • Maintenance # 7 Section # 396.3<br>Can the carrier explain its systematic, periodic maintenance program?

HAZARDOUS MATERIALS

  • Does the carrier transport any amount of hazardous materials?

  • Hazardous Materials # 1 Section # 107.608(a)<br>Is the carrier registered with the Pipeline and Hazardous Materials Safety Administration, and to they have copies of all their registrations for the previous 3 years?

  • Hazardous Materials # 2 Section # 171.15 - Critical<br>Does the carrier promptly report hazardous materials incidents requiring immediate telephone notice to the appropriate authorities?

  • Hazardous Materials # 3 Section # 171.16 - Critical<br>Does the carrier file hazardous materials incident reports when required?

  • Hazardous Materials # 4 Section # 177.800(c) - Critical<br>Does the carrier provide HM training for its drivers?

  • Hazardous Materials # 5 Section # 172.704(a)<br>Do the HM training materials cover the minimum required elements?

  • Hazardous Materials # 6 Section # 177.817(a) - Critical<br>Are the shipping papers used by the carrier properly prepared?

  • Hazardous Materials # 7 Section # 177.817(e) - Critical<br>Does the carrier maintain proper accessibility for shipping papers?

  • Hazardous Materials # 8 Section # 177.841(e) - Acute<br>Does the carrier transport packages bearing a poison label in the same vehicle with any foodstuff or feed for humans or animals?

  • Hazardous Materials # 9 Section # 177.848<br>Is the motor carrier aware that some hazardous materials may not be transported in the same vehicle with other hazardous materials?

  • Hazardous Materials # 10 Section # 180.407(a) - Critical<br>Has the carrier transported a shipment of HM in a cargo tank that has not been inspected or tested in accordance with 180.407?

  • Hazardous Materials # 11 Section # 180.407(c) - Critical<br>Are all of the cargo tanks used for the transportation of hazardous materials periodically inspected and tested in accordance with 180.407?

  • Hazardous Materials # 12 Section # 180.415 - Critical<br>Are cargo tanks that pass inspections or tests required by 180.407 marked?

  • Hazardous Materials # 13 Section # 180.417(a)(1) - Critical<br>Has the carrier retained all of the manufacturer's data report certificates and related papers, as required?

  • Hazardous Materials # 14 Section # 397.5(a) - Acute<br>Does the carrier ensure that vehicles containing Division 1.1, 1.2, or 1.3 (explosive) material is attended at all times?

  • Hazardous Materials # 15 Section # 397.7(a)(1) - Critical<br>Has the motor carrier parked a vehicle containing Division 1.1, 1.2, or 1.3 materials within 5 feet of a traveled portion of a highway or street?

  • Hazardous Materials # 16 Section # 397.7(b) - Critical<br>Has the motor carrier parked a vehicle containing HM other than Division 1.1, 1.2, or 1.3 materials within 5 feet of a traveled portion of a highway or street?

  • Hazardous Materials # 17 Section # 397.13(a) - Critical<br>Has the carrier permitted anyone to smoke when within 25 feet of a vehicle containing Class 1 materials, Class 5 materials, or flammable materials classified in Division 2.1, Class 3, Divisions 4.1, and 4.2?

  • Hazardous Materials # 18 Section # 397.19(a) - Critical<br>Has the carrier furnished all drivers transporting Division 1.1, 1.2, or 1.3 (explosive) material a copy of the rules of Part 397 and/or emergency response instructions?

  • Hazardous Materials # 19 Section # 397.67(d) - Critical<br>Does the carrier have a system to ensure all drivers transporting Class 7 (radioactive) material, Division 1.1, 1.2, or 1.3 explosives, or a poison inhalation hazard Zone A or B materials have a written route plan?

OTHER

  • Does the carrier transport household good or operate any Over The Road Buses (OTBR)

  • Other # 1 Section # 375.211<br>Does the carrier participate in an Arbitration Program?

  • Other # 2 Section 13702.0<br>Does the carrier assess shipper freight charges based upon published tariffs?

  • Other # 3 Section # 375.401(c)<br>Does the carrier provide reasonably accurate estimates of moving charges?

  • Other #4 Section # 375.407(a), 375.703(b)<br>Has the carrier avoided "hostage freight" or other predatory practices?

  • Other # 5 Section # 387.301(a), 387.301(b)<br>Does the HHG carrier have sufficient levels of public liability and cargo insurance?

  • Other # 6 Section # 375.215<br>Does the carrier have a published tariff and is the motor carrier changing the applicable rate (375.215)?

  • Other # 7 Section # 375.213<br>Can the motor carrier identify five documents required to be given to a prospective individual shipper prior to executing an order for service?

  • Other # 8 Section # 49 CFR 37 subpart H<br>Does the carrier have the means to provide accessible over-the-road bus (OTRB) service on a 48-hour advance notice basis by its owned or leased OTRBs?

  • Other # 9 Section # 49 CFR 37 subpart H<br>If the carrier does not have the means then does the carrier have an arrangement with another carrier that operates accessible OTRBs?

Receipt

RECEIPT

  • This audit is used to determine your compliance with the Federal Motor Carrier Safety Regulations (FMCSRs). Any violations discovered may be utilized to help determine the areas of concern that need addressing.

    Your signature for receipt of this report acknowledges your understanding that if any violations are discovered they will be corrected as earliest as possible. You also understand that by failing to correct any violations discovered, you will be held liable for any violations that may be discovered during a compliance review from FMCSA or your States Enforcement Agency.

    You also agree not to hold Employer Advantage and/or its representative liable for any violations discovered during a safety audit or compliance review conducted by any investigator or enforcement officer.

    Refusing to sign this report does not in any way release you from any liability.

  • Assessor Signature

  • Company Official

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