Form Ds-875 - Article 19-A Biennial Behind The Wheel Road Test
Download a blank fillable Form Ds-875 - Article 19-A Biennial Behind The Wheel Road Test in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ds-875 - Article 19-A Biennial Behind The Wheel Road Test with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2ARTICLE 19-A BIENNIAL BEHIND THE WHEEL ROAD TEST
dmv.ny.gov
INSTRUCTIONS TO CERTIFIED EXAMINER
This test shall not be conducted on the same day as the annual defensive driving performance observation. The test should be taken without
l
passengers in the vehicle.
l
If the driver fails the test, he/she is disqualified from driving under Article 19-A. The driver may make a request to the carrier for a reexamination.
DRIVER INFORMATION
M.I.
Driver’s Last Name
First
State Licensed License Class
Endorsements
Restrictions
Expiration Date
Date of Birth (Month/Day/Year)
Driver License ID Number
Driver’s Signature
CARRIER INFORMATION
Carrier/DBA Name
Federal ID Number
19-A Business ID Number
Legal Name (if different)
VEHICLE INFORMATION
Type of Vehicle
Adult Seating Capacity
GVWR
Vehicle Plate Number
State
1. PRE-TRIP TEST
EN-ROUTE (Continued)
Point Value
Point Value
A. Failed to check wheels, tires
5
J. Failed to use proper speed - impedes traffic
5
B. Failed to check validation of required vehicle stickers
5
K. Failed to use proper steering control
5
C. Failed to check lights
5
L. Failed to use proper braking
5
D. Failed to check windshield, wipers, horn, and steering
5
M. Failed to use proper acceleration
5
E. Failed to check emergency equipment:
N. Failed to use proper speed for conditions
DQ
fire extinguisher, and emergency reflectors
5
O. Failed to anticipate and/or identify hazards
5
F. Failed to check seats and restraints when equipped.
5
P. Failed to yield right-of-way
DQ
G. Failed to check passenger entry and emergency exits
5
Q. Failed to use proper lane/s
10
H. Failed to check all gauges, heater, and defroster
5
R. Failed to properly use transmission
5
I. Failed to check all mirrors and adjust as needed
5
S. Failed to observe traffic control devices
DQ
J. Failed to perform static brake check
5
4. PARKING AND BACKING
K. Failed to properly use seat belt
5
A. Failed to leave the vehicle to check rear before
L. Failed to perform 50 ft. brake test
10
backing (no observer)
10
2. DEPARTING
B. Failed to observe (backing)
DQ
A. Failed to signal
5
C. Unable to park
DQ
B. Failed to observe
10
D. Failed to properly position the vehicle
5
C. Failed to use caution
10
E. Stopped too far away from, or hit, curb
5
F. Excessive maneuvers in parking
5
3. EN-ROUTE
A. Failed to properly signal
5
5. SIMULATED PROCEDURES FOR RECEIVING/
B. Failed to observe
10
DISCHARGING PASSENGERS
C. Failed to demonstrate proper judgment approaching/at
A. Failed to use caution at approaching/departing,
intersection; speed, turning, stopping, observing, etc.
10
receiving/discharging points
DQ
D. Failed to make proper lane changes; signals ______,
B. Failed to properly activate warning lights/devices
(where applicable)
observes _______, procedure _______
5
DQ
E. Failed to regularly check mirrors while driving
5
C. Lacked knowledge of proper crossing procedures
as required by NYS Education Department
F. Failed to stop properly at RR crossing
DQ
(where applicable)
DQ
G. Failed to use proper clutch/engine control
5
D. Failed to observe pedestrians/passengers or other
H. Failed to use proper judgment in traffic
10
hazards at receiving and discharge points
DQ
I. Failed to demonstrate proper following distance
DQ
RESULTS
o
o
QUALIFIED
DISQUALIFIED
if disqualified, check all that apply:
o
o
o
40 or more points circled
One or more disqualification (DQ) item(s) circled
Any two, or more, 10 point items circled
Examiner use page 2 for any comments
EXAMINER’S CERTIFICATION (
)
Driver License ID Number
Certified Examiner’s Name
Certificate Number
Certification Class
Endorsements
Restrictions
Expiration Date
CERTIFICATION:
I certify that I currently hold a valid examiner certification as required in accordance with Article 19-A of the New York State Vehicle and Traffic Law,
that I hold the appropriate class driver license with the proper endorsements, that I have tested the above driver in compliance with Section 6.11 and/or Section 6.15 of
Part 6 of the Commissioner’s Regulations and reported the results to the employer. I acknowledge and understand that knowingly making a false statement in connection
with this report or in any proofs or reports in connection with it for the purpose of deceiving or substituting, or causing another person to deceive or substituting, in
connection with this examination or report may subject me to criminal prosecution for a misdemeanor or felony under the Vehicle and Traffic Law and/or Penal Law.
Certified Examiner’s Signature
Date of Test
-
Page 1 of 2
DS-875 (9/16)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal