Fillable Printable Form DS-873 - Driver Annual Defensive Driving Performance Report - New York

Form DS-873 - Driver Annual Defensive Driving Performance Report - New York

I acknowledge discussion of my defensive driving performance with the examiner who observed and rated my performance.

REPORT ON ANNUAL DEFENSIVE DRIVING

PERFORMANCE FOR DRIVER UNDER ARTICLE 19-A

www.dmv.ny.gov

DS-873 (6/15)

SECTION 1 - DRIVER INFORMATION

Driver’s Last Name

Street Address

Street AddressCityStateZip Code

CityStateZip Code

Class of Driver’s LicenseEndorsementsRestrictionsExpiration Date

Client/License ID Number

(from Driver License)

State

FirstM.I.Date of Birth (Month/Day/Year)

SECTION 2 - CARRIER INFORMATION

SECTION 4 - OBSERVATION (may be conducted inside or outside the vehicle) Observation Conducted: oInside oOutside

SECTION 5 - DRIVER ACKNOWLEDGEMENT

__________________________________________________ _______________

(Driver Signature)(Date)

Type of VehicleAdult Seating Capacity

SECTION 3 - VEHICLE INFORMATION

GVWRVehicle Plate NumberState

Satisfactory Unsatisfactory

1. Observation........................................o o

2. Traffic Lane Use

(include center line violation)............o o

3. Speed..................................................o o

4. Properly Signals Intention..................o o

5. Turning................................................o o

6. Vehicle Control....................................o o

Satisfactory Unsatisfactory

7. Obeys Traffic Signs, Signals

and Road Hazard Signs......................o o

8. Observes Proper Following Distance..o o

9. Procedures for Receiving and

Discharging Passengers....................o o

10. Traffic Interaction ................................o o

INSTRUCTIONS TO CERTIFIED EXAMINER:

lRegular observation of a driver’s defensive driving performance must be conducted while the driver is operating the vehicle with passengers.

lThis observation shall NOT be conducted on the same day as the biennial behind-the-wheel road test.

l Discuss performance with driver, complete rating, driver acknowledgement, and examiner certification.

Comments: (required if Unsatisfactory checked above)

Certified Examiner’s Name

Certificate NumberCertification Class Expiration DateEndorsements

Restrictions

Certified Examiner’s Signature

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, and

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.

Client/License ID Number

(from Driver License)

SECTION 6 - EXAMINER’S CERTIFICATION

Date of Observation

Carrier/DBA NameLegal Name (if different)Federal ID Number19-A Business ID Number

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