
CORRECTION REQUEST
OF
ERRONEOUS SAFETY PERFORMANCE HISTORY INFORMATION
This request is made by the driver/applicant in compliance with the Department of Transportation regulations, §391.23,
investigations and inquiries, paragraphs (j)(1) and (2) as printed below.
§391.23(j)(1) Driver wishing to request correction of erroneous information in records received pursuant to paragraph (i) of
this section must send the request for the correction to the previous employer that provided the records to
the prospective employer.
§391.23(j)(2) After October 29, 2004, the previous employer must either correct and forward the information to the
prospective motor carrier employer, or notify the driver within 15 days of receiving a driver’s request to
correct the data that it does not agree to correct the data. If the previous employer corrects and forwards the
data as requested, that employer must also retain the corrected information as part of the driver’s safety
performance history record and provide it to subsequent prospective employers when requests for this
information are received. If the previous employer corrects the data and forwards it to the prospective motor
carrier employer, there is no need to notify the driver.
PART 1: COMPLETED BY THE DRIVER/APPLICANT
TO: Prospective Employer: ________________________________________________________________
Street/P.O. Box: _____________________________________________________________________
City, State, Zip: ____________________________________ Telephone # ______________________
FROM: Driver/Applicant: _____________________________________________________________________
Social Security/I.D. # ________________________
Street: _____________________________________________________________________________
City, State, Zip: ____________________________________ Telephone # ______________________
I request correction of erroneous information in my Safety Performance History. Please forward to the following
prospective employer: Company Name: ______________________________________
Attention: ____________________________________________
Street: ______________________________________________
City, State, Zip: _______________________________________
Explanation of desired correction (attach documents as necessary)____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Driver/Applicant Signature: ______________________________________________ Date: _______/_______/_______
M D Y
Driver: Retain COPY 4 DRIVER RECORD for your files, Submit copies 1, 2, and 3 to your previous employer.
PART 2: COMPLETED BY THE PREVIOUS EMPLOYER
Disposition of the requested information:
Information was corrected and forwarded to the prospective motor carrier employer.
The driver was notified on _____/_____/_____ that the previous employer does not agree to correct the data.
Return copy 3 to the driver.
Information sent to: Company Name: ____________________________________
Attention: __________________________________________
Street: ____________________________________________
City, State, Zip: _____________________________________
Comments: _______________________________________________________________________________________
__________________________________________________________________________________________________
By: ________________________________________ __________________ Release Date: ______/_______/_______
Signature/person providing information Telephone # M D Y
PART 3: COMPLETED BY THE PROSPECTIVE MOTOR CARRIER EMPLOYER
The corrected information was received on _____/_____/_____
Prospective Employer: ______________________________ Location: _______________________________________
Received by: __________________________________________ __________________________________________
Signature Title
COPY 1 PROSPECTIVE EMPLOYER