Article 19-A Biennial Behind The Wheel Road Test

1 CARRIER INFORMATION5. SIMULATED PROCEDURES FOR RECEIVING/DISCHARGING PASSENGERSA. Failed to use caution at approaching/departing,receiving/discharg ing pointsDQB. Failed to properly activate warning lights/devices(where applicable)DQC. Lacked knowledge of proper crossing proceduresas required by NYS Education Department(where applicable)DQD. Failed to observe pedestrians/passengers or otherhazards at receiving and discharge pointsDQ4. PARKING AND BACKINGA. Failed to leave the vehicle to check rear beforebacking (no observer)10B. Failed to observe (backing)DQC. Unable to parkDQD. Failed to properly position the vehicle5E. Stopped too far away from, or hit, curb5F. Excessive maneuvers in parking52. DEPARTINGA. Failed to signal5B. Failed to observe10C.

2 Failed to use caution103. EN-ROUTEA. Failed to properly signal5B. Failed to observe10C. Failed to demonstrate proper judgment approaching/atintersection; speed , turning, stopping, observing, Failed to make proper lane changes; signals _____,observes _____, procedure _____5E. Failed to regularly check mirrors while driving5F. Failed to stop properly at RR crossingDQG. Failed to use proper clutch/engine control5H. Failed to use proper judgment in traffic10I. Failed to demonstrate proper following distanceDQARTICLE 19-A Biennial Behind THE Wheel ROAD TESTINSTRUCTIONS TO CERTIFIED EXAMINERlThis test shall not be conducted on the same day as the annual defensive driving performance test should be taken withoutpassengers in the the driver fails the test, he/she is disqualified from driving under Article 19-A.

3 The driver may make a request to the carrier for a PRE-TRIP TESTP oint ValueA. Failed to check wheels, tires5B. Failed to check validation of required vehicle stickers5C. Failed to check lights5D. Failed to check windshield, wipers, horn, and steering5E. Failed to check emergency equipment:fire extinguisher,and emergency reflectors5F. Failed to check seats and restraints when Failed to check passenger entry and emergency exits5H. Failed to check all gauges, heater, and defroster5I. Failed to check all mirrors and adjust as needed5J. Failed to perform static brake check5K. Failed to properly use seat belt5L. Failed to perform 50 ft. brake test10 EN-ROUTE (Continued)Point ValueJ. Failed to use proper speed - impedes traffic5K. Failed to use proper steering control5L.

4 Failed to use proper braking5M. Failed to use proper acceleration5N. Failed to use proper speed for conditionsDQO. Failed to anticipate and/or identify hazards5P. Failed to yield right-of-wayDQQ. Failed to use proper lane/s10R. Failed to properly use transmission5S. Failed to observe traffic control devicesDQoQUALIFIED oDISQUALIFIEDRESULTS if disqualified, check all that apply:o40 or more points circledoOne or more disqualification (DQ) item(s) circledoAny two, or more, 10 point items circledDS-875 (9/16)DRIVER INFORMATIOND river s Last NameType of VehicleAdult Seating CapacityGVWRV ehicle Plate NumberStateState LicensedLicense ClassEndorsementsRestrictionsExpiration DateDriver License ID NumberDriver s of Birth (Month/Day/Year)VEHICLE INFORMATIONEXAMINER S CERTIFICATION (Examiner use page 2 for any comments)Carrier/DBA NameLegal Name (if different)Federal ID Number19-A Business ID NumberPage 1 of Examiner s NameCertificate NumberCertification Class Expiration DateEndorsements RestrictionsCertified Examiner s SignatureXCERTIFICATION.

5 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 and/or Section ofPart 6 of the Commissioner s Regulations and reported the results to the employer. I acknowledge and understand that knowingly making a false statement in connectionwith 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, inconnection 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 License ID NumberDate of TestCERTIFIED EXAMINER S COMMENTS:DS-875 (9/16)Page 2 of