Yearly driving record review form: the MVR check and sign-off for each NEMT driver

How to use this form

Complete one form for each driver every year and pin the pulled driving record behind it. The form does two jobs. It shows that someone looked at the record, and it shows what that person decided. That pair is what the federal rule for commercial motor vehicle drivers asks employers to keep, and it is what a broker auditor wants to see when it asks for your driver files. How a record is pulled and what it shows are explained in what an MVR is. This page is the review that comes after the pull.

Print the next review date on every form. A rule that says “at least once every 12 months” is easiest to meet when the last form already names the following due date, and Part 1 has a line for it. Reviewing every driver in the same month is simpler to run than counting from each hire date, as long as no driver goes past 12 months between pulls. Where you use alerts between pulls, as described in continuous MVR monitoring, this form is still the yearly baseline the alerts fill in around.

Get consent first. The pull goes through the written authorization or the driving record consent in the background check authorization form, and the first one should say it covers checks during employment.

The form

Part 1: Driver and review dates

Part 2: Records pulled

List every state that licensed the driver during the period, even one the driver has left. Staple each record behind this form.

Part 3: What the record shows

Part 4: Limits checked

Fill the first column once, from your contracts and your insurance policy, and reuse it for every driver. Where two sources set different windows, the driver has to meet each one separately.

Part 5: Decision

• Qualified. The driver stays on the schedule.
• Qualified with follow-up. Retraining or a ride-along by [date], and a fresh record pulled by [date, such as 90 days out].
• Off the schedule until [what has to change, with the date it will be checked].

Driver told of the result on [date] by [name].

Part 6: Reviewer’s note and sign-off

I reviewed the motor vehicle record dated [date] for [driver name] on [date of review].

Reviewer name and title: ______________________ Signature: ______________________ Date: __________

What the federal yearly review asks for

A carrier under the rule has two jobs each year. First it asks for a fresh motor vehicle record on every driver it employs. The request goes to each licensing authority where the driver held a commercial license or permit during the period, and the record has to cover at least the previous 12 months. Then someone at the company reads the record and decides whether the driver still meets the minimum requirements for safe driving or has become disqualified under 49 CFR 391.15 (391.25(a) and (b)).

The reading has content rules. The reviewer weighs any evidence of federal safety rule violations, the driver’s accident record, and any violations of vehicle laws, and treats speeding, reckless driving and impaired driving as the heaviest items because they show disregard for public safety (391.25(b)). Part 3 puts those items on one page. The record then goes into the driver’s qualification file with a note naming the reviewer and the date (391.25(c)).

Two details help with the file. First, the driver no longer writes a yearly list of convictions. Section 391.27 is now reserved: FMCSA’s 2022 rule, effective May 9, 2022, removed the driver’s list as largely duplicative of the record inquiry, and said the record is a more accurate account of a driver’s convictions than the driver’s own report. Second, the qualification file lasts as long as the driver works for the carrier plus three years, and the yearly record and review note may come out of it three years after they were made (391.51(c) and (d)).

Whether the rule reaches a given van fleet depends on the vehicle and the trip. The USDOT number guide explains when federal driver rules apply to NEMT, including the exception for transporting sick and injured persons (390.3T(f)(4)). A company outside the rule can still use the form as it stands, because the payers below ask for the same record on the same yearly cycle.

What payers add to the yearly pull

Each payer sets its own look-back and its own freshness rule, so one driver’s record has to be read against several clocks.

• MTM. Its provider agreement, in the January 2023 version that Pennsylvania’s Department of Human Services posts, lists a motor vehicle driving record report for the previous three years, annually, among the items a provider keeps on each driver, and says the file must be given to MTM on request.
• Modivcare. Its reminder to out-of-network providers calls for a copy of each driver’s driving history, traffic violations included, every year, kept for 10 years and produced within three business days of a request. The reminder adds that Modivcare audits a sample of those providers each quarter.
• LCP Transportation. Its July 2026 vendor credentialing sheet wants each motor vehicle report to be less than six months old at submission. A record pulled in January is too old for a submission in August.
• Transdev Health Solutions, Hawaii. The driver checklist on its provider page asks for a five-year motor vehicle report, no moving violations and no suspensions for moving violations in the past year, no DUI-type convictions, and at most two preventable accidents over three years. The file dates from July 2024, and the provider page still links to it.
• Kentucky. 603 KAR 7:080 has the broker or subcontractor give the Transportation Cabinet documentation certifying that each driver has no more than two convictions for moving violations in the last three years.

The windows are not uniform. A driver with one minor ticket from six months ago passes the Kentucky rule and fails the Hawaii checklist, which is why Part 4 asks you to record each source separately. The wider table of broker limits is in the MVR entry.

When the record shows a problem

Act on the license first and the count second.

• A suspended, revoked or expired license takes the driver off the schedule that day. For a commercial motor vehicle driver, 49 CFR 391.15(b) disqualifies the driver for as long as the license, permit or privilege is lost, and requires the driver to tell the employer of a suspension or revocation notice before the end of the next business day. The same MTM agreement draws that line for its trips: no driver whose license is suspended, expired or revoked.
• A count that breaks one payer’s limit and not another’s takes the driver off that payer’s trips only. Mark the limit that was missed in Part 4.
• A payer that wants to hear about it. Modivcare’s 2025 attestation commits the provider to telling Modivcare right away about any crash, incident or moving violation tied to a driver or van on its trips. That report cannot wait for the yearly review.
• A record from a screening company that leads you to act against the driver starts with the pre-adverse action notice, before the decision is final.

Write the decision and the date in Part 5 whichever way it goes. A clean record still gets a signed form.

Setting the next review date

Add the next review as a credential on each driver in HealthRide’s fleet records, with the due date from Part 1. A reminder arrives before the date, and an expired one shows as a warning before a trip is assigned.