Form 4 Driver Activtiy Form

FMCSA Under 21 Military Commercial Drivers Pilot Program

Motor Carrier Data Collection Form

OMB Control Number: XXXX-XXXX Expiration Date: MM/DD/YYYY

Privacy Statement

• Authority: 49 CFR 381.400; Pub. L. 114-94, Dec. 4, 2015, 49 USC 31315 Section 5404

• Purpose: FMCSA will be collecting this data for use in the research effort title “Pilot Program to Allow 18- to 21-Year-Old Persons with Military Driving Experience to Operate Commercial Motor Vehicles (CMVs) in Interstate Commerce”. Additionally, this data may be used for future undetermined research efforts, but cannot be used for enforcement purposes.

• Routine Uses: In addition to those disclosures permitted under 5 USC 552a(b) of the Privacy Act of 1974, additional disclosures may be made in accordance with the U.S. Department of Transportation (DOT) Prefatory Statement of General Routine Uses published in the Federal Register on December 29, 2010 (75 FR 82132), under ‘‘Prefatory Statement of General Routine Uses’’ (available at http://www.dot.gov/privacy/privacyactnotices).

• Disclosure: The disclosure of this data is voluntary, however, failure to provide the requested information may result in dismissal from participating in the pilot program. For drivers granted privilege to operate under an exemption through this program, dismissal from the pilot program will result in the denial to continue operating under that exemption.

This form is to be used to record driver activity and safety outcome data for the reporting period.
MOTOR CARRIER INFORMATION
MOTOR CARRIER NAME				U.S. DEPARTMENT OF TRANSPORTATION NUMBER			REPORTING START DATE (mm/dd/yyyy)		REPORTING END DATE (mm/dd/yyyy)
DRIVER ACTIVITY & SAFETY OUTCOME DATA FOR THE REPORTING PERIOD
DRIVER NAME	STATE/ COMMERCIAL DRIVER LICENSE NUMBER	ALL CRASHES	DOT REPORTABLE CRASHES	ROADSIDE INSPECTION VIOLATIONS (CSA POINTS ACCRUED)	TOTAL NO. OF ALL INSPECTIONS	MOVING VIOLATIONS	MOTORIST INCIDENT REPORTS	NEAR CRASHES (as recorded by the on-board monitoring system if installed)	CRITICAL EVENTS (as recorded by the on-board monitoring system if installed)	DISQUALIFYING EVENT (Yes or No)
OTHER ATTACHMENTS
If the driver was involved in any crashes during the reporting period, attach the Motor Carrier’s Post-Crash Investigation Summary and the Law Enforcement Crash Report of the investigating law enforcement agency. Submit driver record for participating drivers. Submit On-Board Monitoring System (OBMS) Logs for the drivers, if installed, on the vehicles. Submit any investigative findings from crashes that have occurred. Specify the Disqualifying Event(s) for the drivers if one occurred.

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is XXXX-XXXX. Public reporting for this collection of information is estimated to be approximately XX minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.