Fitness Evaluation Form
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1FITNESS EVALUATION FORM
Company Name:
Address:
Safety Fitness Reviewer:
YES
NO*
Does the applicant meet the minimum level of fitness for this classification approval?
*If NO, Why?
COMMENTS:
Is the applicant requesting authorization(s) for classification or transport of the materials indicated below:
YES
NO
Explosives (Class 1.1, 1.2, 1.3, or 1.4)
Division 4.1
YES
NO
Division 5.1
YES
NO
Division 5.2
YES
NO
In the 5-year period prior to the application, the applicant has been involved, directly or indirectly, in the type and number
of hazardous materials incidents below:
More than 1 “serious incident” involving any hazardous material:
YES
NO
More than 1 hazardous material incident involving any § 172.504 Table 1 and any material listed
YES
NO
above:
More than 1 hazardous material incident involving a cargo tank, motor vehicle, railroad tank car,
YES
NO
or other bulk packaging:
More than 2 hazardous materials incidents involving any § 172.504 Table 2 materials in
YES
NO
intermediate bulk or portable tank packaging:
More than 30 hazardous materials incidents involving any § 172.504 Table 2 materials in non-
YES
NO
bulk packagings:
In the 5-year period prior to the application, the applicant has received:
Four civil enforcement cases:
YES
NO
YES
NO
Four warning letters:
YES
NO
A combination totaling four civil enforcement cases and/or warning letters:
SAFER REVIEW:
A Motor Carrier Safety Rating of less than satisfactory according to the Federal Motor Carrier
YES
NO
Safety Administration’s Safety and Fitness Electronic Records System (SAFER):
A HAZMAT
Out-of-Service percentage of greater than the national
YES
NO
SAFER:
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