Self Audit AUDIT HiddenWho is this From? Total Safety Systems Audit Date* MM slash DD slash YYYY Company Name audit is being conducted for:* This information is used to sort only.Please Enter Employee/Applicant/File Name:* First Last Please enter the file name you wish to Audit. Do you want to send this audit result to someone other than our self?* No Yes Please Enter Auditor Name:* First Last This is your name.Please Enter Auditor Email:* Enter Email Confirm Email Please enter your preferred email address for a copy of your audit to me mailed to. Please enter Recipient Name:* First Last This is who you will be submitting the final audit to when it has been completed. Please Recipient Email:* Enter Email Confirm Email When completed, an email with an attached PDF will be sent to this address. This PDF can be printed for paper storage file systems or migrated for electronic storage file systems, and will be titled "COMPLIANCE AUDIT (file name)"What Type of Audit would you like to do?* DOT Qualification File Audit Personnel File Audit Payroll File Audit Health File Audit Training File Audit Random File Audit Summary Audit Finding and Documentation Renewals File Audit DOT Qualification File AuditBoth the Driver Qualification and Safety Performance History Files must be retained for as long as the safety-sensitive individual is employed by the company, and for three years thereafter. The following documentation may be discarded from the Driver Qualification File three years from the date of execution: Annual List of Violations, Annual Inquiry to Sate Agencies, Annual Review of Driving Record, Medical Examiner’s Certificate, Safety Performance Evaluation Certificate (if applicable)Please select the items that are present in the file:* None APP (Application for Employment) CDL (Commercial Driver License) or EHCDL (Enhanced Commercial Driver License) MEC (Medical Examiner Certification/Card) MVR (Motor Vehicle Record) COC (Chain of Custody form for pre-employment drug test) DTR (Drug Test Results) RT (Road Test or Equivalent, some companies accept a valid CDL) CFR (Cfr 49 Previous employer request for each CDL employer listed on APP have been sent at least once) NRCME (National Registry of Certified Medical Examiners search results) HOS (Previous Seven Days statement) Certificate of Compliance Stating only one license will be held FMCSR Receipt for information DAP (Drug and Alcohol Policy and educational materials receipt) Please select the items that are are needed to complete the file:* None APP (Application for Employment) CDL (Commercial Driver License) or EHCDL (Enhanced Commercial Driver License) MEC (Medical Examiner Certification/Card) MVR (Motor Vehicle Record) COC (Chain of Custody form) DTR (Drug Test Results) RT (Road Test or Equivalent, some companies accept a valid CDL) CFR (Cfr 49 Previous employer request for each CDL employer listed on APP have been sent at least once) NRCME (National Registry of Certified Medical Examiners search results) HOS Previous Seven Days statement Certificate of Compliance Stating only one license will be held FMCSR Receipt for information DAP (Drug and Alcohol Policy and educational materials receipt) Application InformationVerify True and Correct Statement present on the application.* Yes No Application indicates Driver held another license within three years.* Yes No Is previous License information present in file?* Yes No Does Application cover the previous seven seven years of residency?* Yes No Does the Application cover the appropriate employment history?* Yes No Three years for all employment, ten for Commercial driving jobs. Does Application (or MVR) Indicate any collisions or citations?* Yes No Does Application (or MVR) identify which state these citations or collisions were in?* Yes No Does drive experience total miles driven calculate correctly for time period stated?* Yes No Do you have any reason to suspect this application needs additional information added?* Yes No Any Problems in this section?* Yes No Please explain problems.*CDL InformationLicense Number on Document* CDL Expiration Date* MM slash DD slash YYYY State of Issue* State / Province / Region Is this CDL or DL from out of your state of operation?* No Yes New State residents have 90 days to transfer a CDL or DL. Would you like to send yourself a reminder?* Yes Please. No Thanks. Date of Birth* MM slash DD slash YYYY Gender listed on CDL* Male Female CDL Class* Class A Class B Class C Permit Non CDL Driver Endorsements* (P1) Passenger (S) School Bus (H) Hazmat (M) Motorcycle (T) Doubles/Triples (N) Tank Vehicle (X) Tanker and Hazardous Materials Other Please Explain Other* Restrictions* None (U) Intrastate Only (C) Corrective Lenses (L) Air Brakes (V) Waiver (medical) (E) No manual Transmission Other Please Explain Other* Does the state you are auditing in offer online research tools?* Yes No Some states have online tools that allow free check of current license status. Is drivers license research status present in file?* Yes No Some states have online tools that allow free check of current license status. If this item is present, note it here. Upload front of License here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*MEC InformationMEC Expiration Date* MM slash DD slash YYYY MEC Inter-State or Intra-State* Inter-State Intra-State MEC Expiration date matches MVR* Yes No MVR Does not have information listed Verification of compliant medical examiner in file.* Yes No Date of Issue and Date of Expiration present on MEC card.* Both are present One or more is missing MEC exception* None Corrective Lenses Waiver/Exemption Certificate Hearing Aid Driving within an exempt intracity zone Qualified by operation of 49 CFR 391.64 Type of Waiver required* Diabetes Vision Amputee/Loss of Limb Waiver/Exemption document pesent* Present Not Present Upload front of MEC here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*MVR InformationMVR Expiration Date* MM slash DD slash YYYY MVR expires 12 Months after pull date. Add 12 months to date of document.MVR Certification matches the MEC (Medical Examiner Certificate) Certification.* Both are Inter-State Both are Intra-State They do not match Upload front of MVR here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*COC InformationCOC has been properly marked with FMCSA panel.* Yes No COC properly marked as "Pre-Employment".* Yes No COC has correct company name on it.* Yes No COC has been correctly signed by Donor.* Yes No Upload COC here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*DTR InformationDTR is in correct employee file* Yes No DTR is NEGATIVE for drugs in system.* Yes No DTR is correctly marked FMCSA.* Yes No DTR is correctly marked DOT Panel.* Yes No DTR is correctly marked Pre-Employment.* Yes No DTR is correctly marked with employer name.* Yes No Any anomalies such as Dilute noted on DTR?* Yes No Please explain* Is documentation present indicating when employee was entered into the drug pool?* Yes No CRITICAL ITEM!!Enter Enrollment Date* MM slash DD slash YYYY Upload DTR here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*RT InformationDoes this motor carrier require a road test?* Yes No Was driver identified as having the skills necessary?* Yes No Were the miles properly listed for the Road Test?* Yes No Does road test identify equipment type tested in?* Yes No Is the Road Test properly signed?* Yes No Is there an "Equivalent of Road Test" in file?* Yes No Upload RT here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*CFR InformationHow many CFR 49 items were provided* 1 2 3 4 5 6 Was the #1 CFR sent twice?* Yes No Was the #1 CFR response received??* Yes No Was the #2 CFR sent twice?* Yes No Was the #2 CFR response received?* Yes No Was the #3 CFR sent twice?* Yes No Was the #3 CFR response received?* Yes No Was the #4 CFR sent twice?* Yes No Was the #4 CFR response received?* Yes No Was the #5 CFR sent twice?* Yes No Was the #5 CFR response received?* Yes No Was the #6 CFR sent twice?* Yes No Was the #6 CFR response received?* Yes No Was any documentation NEEDING TO BE sent to FMCSA for failure to respond?* Yes No Possibly Please Explain Was any documentation sent to FMCSA for failure to respond?* Yes No Office of Drug & Alcohol Policy & Compliance 1200 New Jersey Ave, SE W62-300 Washington, DC 20590 United States ODAPCWebMail@dot.gov Phone: (202) 366-3784 Alt: (800) 225-3784 Fax: (202) 366-3897Upload CFR here if necessary. Drop files here or Select files Max. file size: 20 MB. Office of Drug & Alcohol Policy & Compliance 1200 New Jersey Ave, SE W62-300 Washington, DC 20590 United States ODAPCWebMail@dot.gov Phone: (202) 366-3784 Alt: (800) 225-3784 Fax: (202) 366-3897Office of Drug & Alcohol Policy & Compliance 1200 New Jersey Ave, SE W62-300 Washington, DC 20590 United States ODAPCWebMail@dot.gov Phone: (202) 366-3784 Alt: (800) 225-3784 Fax: (202) 366-3897Any problems in this section?* Yes No Please explain problems.*NRCME InformationNRCME doctor verification document is present in file.* Yes No NRCME doctor number is a valid number.* Yes No NRCME doctor name matches that listed on MEC card.* Yes No Upload NRCME Results here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*HOS InformationIs the Previous Seven Days document correctly completed?* Yes No Please Explain*Is the Previous Seven Days document correctly signed and dated?* Yes No Upload Previous Seven Days here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*Certificate of Compliance InformationDoes Certificate of Compliance have DL number present?* Yes No Is Certificate of Compliance signed and dated correctly?* Yes No Upload Certificate of Compliance here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*FMCSR InformationFMCSR receipt is present in file.* Yes No FMCSR receipt is signed by employee.* Yes No FMCSR receipt is in correct employee file.* Yes No Upload FMCSR Receipt here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*DAP InformationDAP receipt for information is present.* Yes No DAP receipt for information is signed by employee.* Yes No DAP is in correct employee file.* Yes No DOT Qualification Notes, requests or special instructions.Upload DAP Receipt here if necessary. Drop files here or Select files Max. file size: 20 MB. Any problems in this section?* Yes No Please explain problems.*Personnel FileItems present in Personnel File* CBC Authorization (Criminal Background Check) CBC Response PSP Authorization (Pre-Employment Screening Program-FMCSA) PSP Report MVR Auth Initial (Motor Vehicle Record Authorization-Initial Pull) MVR Auth Annual(Motor Vehicle Record Authorization-Annual Pull) Code of Conduct or Similar (Employee manual or other document) Insurance Company Approval Request to Add to Insurance Policy Fuel Card or PIN order Items needed in Personnel File* None CBC Authorization (Criminal Background Check) CBC Response PSP Authorization (Pre-Employment Screening Program-FMCSA) PSP Report MVR Auth Initial (Motor Vehicle Record Authorization-Initial Pull) MVR Auth Annual(Motor Vehicle Record Authorization-Annual Pull) Code of Conduct or Similar (Employee manual or other document) Insurance Company Approval Request to Add to Insurance Policy Fuel Card or PIN order Payroll FilePayroll Document Present* I9 Present W4 Present PAN Present (Personell Action Notification) I9 DocumentI9 Document items present Document is current (upper right corner expiration) I9 signed section 2 with two dates I9 list complete Documents listed on I9 present in file Birthdate listed on I9 Telephone number listed on I9 I9 Document items needed None Document is current (upper right corner expiration) I9 signed section 2 with two dates I9 list complete Documents listed on I9 present in file Birthdate listed on I9 Telephone number listed on I9 W4 DocumentW4 Document items present* Document is current Section 1 Completed (name/address) Section 2 Completed (SS Number) Section 3 Completed (single/married/married filing singly) Section 4 Completed (last name differs) Section 5 Completed (total allowances) Section 6 Completed (additional amount) Section 7 Completed (exempt) Employee Signature and date Section 8 Completed (employer name and address) Section 10 Completed (EIN number) W4 Document items needed* None Document is current Section 1 Completed (name/address) Section 2 Completed (SS Number) Section 3 Completed (single/married/married filing singly) Section 4 Completed (last name differs) Section 5 Completed (total allowances) Section 6 Completed (additional amount) Section 7 Completed (exempt) Employee Signature and date Section 8 Completed (employer name and address) Section 10 Completed (TIN Number) PAN Document (Personell Action Notification)PAN Document items Present Rate of pay listed on PAN Employee status listed on PAN Employee department listed on PAN PAN Document items Needed None Rate of pay listed on PAN Employee status listed on PAN Employee department listed on PAN Health FileUntitled First Choice Second Choice Third Choice Training FileTraining Items Present* Enrolled in online training Driver On-Boarding course completed 101 Course Completed 102 Course Completed 103 Course Completed Policies and Procedures Completed Random Audit FileThis audit should be performed based on your Random Selection names. Begin with the selection list, if any failures occur, work in brackets (Selection last name is Johnson, Bracket I and K for failure selections) in both directions until you have found complete files. Has the employee been employed for more than one year?* Yes No Please enter the date of hire* MM slash DD slash YYYY Does the employee have any items that have been renewed?* Yes No Which items have renewed since Date of Employment. MVR (Motor Vehicle Record/Annual Certification of Violations) CDL (Commercial Driver License) MEC (Medical Examiners Certificate) New expiration date of MVR* MM slash DD slash YYYY Was MVR renewed prior to the expiration of the last MVR?* Yes No Is the Annual Certification of Violations signed and dated properly?* Yes No Does the New MVR status match the MEC card on file?* Yes No New expiration date of CDL* MM slash DD slash YYYY Is the new CDL consistent with the MVR on file?* Yes No Is documentation present in file that indicates a Driver License Status Check has been done?* Yes No New expiration date of MEC* MM slash DD slash YYYY Does the New MEC Status match the MVR on file?* Yes No Is a new NRCME (National Registry of Certified Medical Examiners search results) present in file?* Yes No Is the new doctor certified?* Yes No Does the doctors name on the MEC card match the Search Results?* Yes No Are both dates of issue and expiration listed on the MEC card?* Yes No Is the Doctors phone number written on the card?* Yes No Is this file ready to be finalized?Does this file appear to be ready to go? Yes No Please Explain needed action items.*Good to GoGood-to-Go-Please enter name of company recipient you would like to notify:* First Last Good-to-Go-Please enter email of company recipient you would like to notify:* Enter Email Confirm Email Not good to GoNot Good-Please enter name of company recipient you would like to notify:* First Last Not Good-Please enter email of company recipient you would like to notify:* Enter Email Confirm Email Summary Audit Finding and DocumentationIs this file DOT compliant or Not?* This file is a DOT Compliant file This file is NOT a DOT compliant file Please explain the summary issues/facts:Were actions taken to make the file COMPLIANT? Yes No Please explain the summary actions taken to make this file compliant:*Do you believe there is any possibility that this file can be made compliant at this time?* Yes No Please provide information or instructions on how to make this file compliant at this time:Renewals File AuditBoth the Driver Qualification and Safety Performance History Files must be retained for as long as the safety-sensitive individual is employed by the company, and for three years thereafter. The following documentation may be discarded from the Driver Qualification File three years from the date of execution: Annual List of Violations, Annual Inquiry to Sate Agencies, Annual Review of Driving Record, Medical Examiner’s Certificate, Safety Performance Evaluation Certificate (if applicable)Documents Present* CDL MEC MVR MEC RenewalsMEC Recordkeeping* Currently Hawaii, Utah and Oregon do not report to MVR The Federal Motor Carrier Safety Administration (FMCSA) officially published its highly anticipated final rule delaying “portions” of the regulation tying the Commercial driver’s license (CDL) to the holder’s medical qualifications. Driver recordkeeping Non-excepted, interstate CDL holders must continue to carry a copy of the medical examiner’s certificate while on duty until January 30, 2015. Non-excepted, interstate Commercial Learner’s Permit (CLP) holders must continue to carry a copy of the medical examiner’s certificate while on duty until July 8, 2015. Carrying the medical examiner’s certificate is required for both CDL and CLP holders even if they have self-certified and submitted the medical examiner’s certificate to the state licensing office and the information appears on their driving record (i.e., motor vehicle report (MVR)). If a driver’s state of licensing is currently collecting the self-certifications and medical certificates, all CDL/CLP drivers must continue to submit the required documentation to the state licensing office, including subsequent renewals of their medical certificates, or face a downgraded license. Motor carrier recordkeeping Motor carrier recordkeeping would be based on whether or not the state licensing office has entered the medical information onto the driver’s MVR. The employer must verify the medical certification status, and subsequently the CDL status, via the MVR if the report shows medical certification information. (The driver submitted it, and the state posted it.) This was the case under the previous verbiage as well. Similarly, if the state licensing office has collected the self-certification and medical examiner’s certificate for its CLP holders and the information appears on the driver’s MVR, the motor carrier is responsible for obtaining a copy of the MVR to verify the information. If the state of licensing has not collected the self-certification and medical certification on the CDL or CLP holders — or has not entered the information it has collected onto the driver’s record — the motor carrier may continue to use the medical examiner’s certificate in the DQ file as proof of qualification for non-excepted, interstate CDL or CLP drivers. Should the state implement the process through the course of the year (i.e., driver submitted it; state posted it to the MVR), the motor carrier would be responsible for requesting the MVR from the state of licensing to verify the driver’s medical and license status. No later than January 30, 2015, dependent upon the state’s implementation date, all motor carriers must have MVRs for all non-excepted, interstate CDL drivers showing the medical status. No later than July 8, 2015, dependent upon the state’s implementation date, all motor carriers must have MVRs for all non-excepted, interstate CLP drivers showing the medical status. Drivers and motor carriers will need to consult with their state licensing agencies to determine which deadlines apply.MEC Template* Yes No Is the Issue date listed on the document? Yes No Is the Expiration date listed on the document? Yes No Do the Expiration date and Issue date appear to be the same handwriting? Yes No Do the Expiration date and Issue date appear to be consistent in time for the receipt of the MEC card? Yes No Are there any waivers noted? Yes No What are the waivers?* Corrective Lenses Diabetes Prosthetic Limb Other Is this an Interstate or Intrastate Card? INTER State INTRA State Doctor is registered on the National Registry of Certified Medical Examiners (NRCME) system? Yes No CDL RenewalsCDL Template Yes No MVR RenewalsMVR Template Yes No How many MVRs are present in the renewals file? 1 2 3 More than 3
