Page 214 - Personnel Policy and Procedures Manual

Form RM-MVR-RF MVR Review Form

Name Date of MVR

Dept: Job Title

License Status: # Current Points:
Tickets in last 3 years (current employees) or # of Weight Total List all
7 years (potential employees): Incidences /Incident Score Date/Violation/Pts
At-fault accident with fatality X 10 =
DUI/operating while impaired X 8 =
Chemical test refusal X 8 =
Fleeing police X 8 =
Reckless/careless driving X 6 =
Driving under suspended license X 6 =
Leaving scene of accident X 4 =
Speeding (≥15 mph or over 75 mph) X 3 =
At-fault accident X 2 =
Speeding (<15 mph over limit) X 2 =
Improper/illegal lane change or turn X 2 =
Following too closely X 2 =
Traffic signal offenses X 2 =
Failure to yield X 1 =
Failure to signal X 1 =
Operating a defective vehicle X 1 =
Other X 1 =
Describe:
MVR Score Subtotal:
3 Pt adjustment made if no violations within last 3 Adjustment:
years (potential employees only)
Other issues with Record:

TOTAL SCORE:
Total Scores are:
10 or more Unacceptable
7 – 9 Questionable
4 – 6 Marginal
0 – 3 Acceptable

Reviewer: Date:
Notification: Date:
Recommendation:
Reason:

All Rights Reserved – As approved by the Commission on 05-07-2019 213 | P a g e