Form Ds-873 - Report On Annual Defensive Driving Performance For Driver Under Article 19-A
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1REPORT ON ANNUAL DEFENSIVE DRIVING
PERFORMANCE FOR DRIVER UNDER ARTICLE 19-A
dmv.ny.gov
INSTRUCTIONS TO CERTIFIED EXAMINER:
Regular observation of a driver’s defensive driving performance must be conducted while the driver is operating the vehicle with passengers.
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This observation shall NOT be conducted on the same day as the biennial behind-the-wheel road test.
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Observation may be conducted either inside or outside of the bus that the driver is operating.
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Discuss performance with driver, and complete the Observation, Driver Acknowledgement, and Examiner’s Certification sections below.
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SECTION 1 - DRIVER INFORMATION
Driver’s Last Name
First
M.I.
Date of Birth (Month/Day/Year)
Driver License ID Number
State Licensed
License Class
Endorsements
Restrictions
Expiration Date
SECTION 2 - CARRIER INFORMATION
Carrier/DBA Name
Legal Name (if different)
Federal ID Number
19-A Business ID Number
SECTION 3 - VEHICLE INFORMATION
Type of Vehicle
Adult Seating Capacity
GVWR
Vehicle Plate Number
State
o
o
SECTION 4 - OBSERVATION
Observation Conducted:
Inside
Outside
S
U
S
U
ATISFACTORY
NSATISFACTORY
ATISFACTORY
NSATISFACTORY
o
o
o
o
1. Observation ........................................................
6. Vehicle Control ........................................................
o
o
o
o
2. Traffic Lane Use (include center line violation) ..
7. Obeys Traffic Signs, Signals and Road Hazard Signs..
o
o
o
o
3. Speed..................................................................
8. Observes Proper Following Distance ......................
o
o
o
o
4. Properly Signals Intention ..................................
9. Procedures for Receiving and Discharging Passengers
..
o
o
o
o
5. Turning ................................................................
10. Traffic Interaction ......................................................
Comments: (required if Unsatisfactory is checked above)
SECTION 5 - DRIVER ACKNOWLEDGEMENT
I acknowledge discussion of my defensive driving performance with the examiner who observed and rated my performance.
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__________________________________________________
_______________
(Driver’s Signature)
(Date)
SECTION 6 - EXAMINER’S CERTIFICATION
Driver License ID Number
Certified Examiner’s Name
Certificate Number
Certification Class
Endorsements
Restrictions
Expiration Date
CERTIFICATION: I certify that the above report is, to the best of my knowledge, true and correct, that I personally observed the above driver’s
defensive driving performance, 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, and that I hold the appropriate class driver’s license with the proper endorsements. 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 substitute, 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 Observation
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DS-873 (9/16)
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