<p>Title of Form: DISMISSAL FOR REASON INVOLVING PUPIL TRANSPORTATION SAFETY</p><p>California law (Vehicle Code §1808.8a) requires carriers to report to the department any driver dismissed for a cause relating to pupil transportation safety. The carrier must report within five days of the date of dismissal. </p><p>Use this form to report such drivers to the Department of Motor Vehicles (DMV). </p><p>Mail completed forms to the:</p><p>Driver Safety Review Unit P.O. Box 942890 Sacramento, CA 94290-0001, </p><p>Attn: MS J234. </p><p>You will be notified of the action taken by the department. </p><p>IMPORTANT NOTICE: Do not report drivers who quit, retire, transfer, or are fired for reasons such as tardiness, absentee- ism, Insubordination, dishonesty, or other poor work habits not related to pupil transportation safety. Use this form only to report drivers who, for safety reasons, should not be transporting pupils and who have been fired for that reason. Do not report routine terminations or retirements. </p><p>If you’re filling this form out on the computer, merely tab to move from blank to blank. When you’re finished, print the form and obtain the signatures. When prompted to save the document, you may choose no – the form remains a blank for the next time you use it. If you would like to save it, you should save it as a different file name. If you have any questions, please contact Terri Prichard at 209-389-4054 or [email protected] DISMISSAL FOR REASON INVOLVING PUPIL TRANSPORTATION SAFETY</p><p>California law (Vehicle Code §1808.8a) requires carriers to report to the department any driver dismissed for a cause relating to pupil transportation safety. The carrier must report within five days of the date of dismissal. </p><p>Please use this form to report such drivers to the Department of Motor Vehicles (DMV). No envelope is needed, Simply fold and staple so that only the DMV address (on reverse) shows, stamp, and mail. </p><p>It additional copies of this form are needed, you may duplicate as many copies as you wish. Mail completed forms to the Driver Safety Review Unit, P.O. Box 942890, Sacramento, CA 94290-0001, MS J234. You will be notified of the action taken by the department. </p><p>IMPORTANT NOTICE: Do not report drivers who quit, retire, transfer, or are fired for reasons such as tardiness, absentee- ism, Insubordination, dishonesty, or other poor work habits not related to pupil transportation safety. Use this form only to report drivers who, for safety reasons, should not be transporting pupils and who have been fired for that reason. Do not report routine terminations or retirements. </p><p>Please type or print legibly the following information. DRIVERS FULL NAME BIRTHDATE TERMINATION DATE DRIVER LICENSE NUMBER</p><p>Reason for Termination: Please give details concerning reason for dismissal based on pupil transportation safety in the space provided below. If the driver was dismissed based on the results of a medical exam or drug test, if available, please attach a copy of the medical exam or lab report, or include the name address, and phone number of the physician or laboratory along with other details concerning the reason for termination.</p><p>DRIVER’S FULL NAME YOUR WORK PHONE NUMBER</p><p>COMPANY NAME</p><p>COMPANY ADDRESS</p><p>I am reporting this driver as required by Section 1608.8(a) of the California Vehicle Code</p><p>X______Signature Date</p><p>DMV COMPLETES THIS SECTION DATE RECEIVED COMMENT INPUT DATE REVIEWED BY DATE</p><p>EMPLOYER CONTACTED ADDITIONAL INFORMATIN OBTAINED FROM EMPLOYER, IF CONTACTED Yes No COMPANY ADDRESS</p><p>ACTION TAKEN BY DMV</p><p>DATE NOTICE OF ACTION SENT TO EMPLOYER</p><p>DL 128 (rev. 8/97)</p>