Docstoc

M-805 - Pennsylvania Department of Transportation

Document Sample
M-805 - Pennsylvania Department of Transportation Powered By Docstoc
					                                                                                 INSTRUCTIONS
1.   This form is to be submitted monthly for every personnel vehicle (automobile, station wagon, van, SUV, or pickup truck utilized as a staff vehicle.

2.   The assigned operator data block is to be completed by the employee permanently assigned to the vehicle.

3.   The following information will be completed daily by the operator of the personnel vehicle. For each day operated, beginning with the first day of the month,
     the operator shall record the beginning and ending odometer reading, the miles operated (stop minus start), the destination (originating point to farthest place
     of travel), travel status code (F or H), first and last name of operator (same operator may use ditto marks or arrow), the operator's organization code, the
     allotment, cost function that the use is to be charged, and a state project number, if applicable.

4.   At the end of the month, complete the form by inserting totals for the number of miles operated, and the total number of days indicated for the status code
     "H". The employee assigned to the vehicle and his supervisor must sign the form in the designated area. Forward the completed form to the Organization
     Automotive Officer on the first working day of the next month.

5.   Instructions for the further distribution and processing of the M-805 are contained in Chapter 10, Section 12, page 40, of the Maintenance Manual.

6.   Travel Status Codes: "F"- "Field"- vehicle operated in the field or on business assignment.
                          "H"- "Home to Headquarters"- vehicle was operated for transportation from home to headquarters. (SEE NOTE)

                            NOTE:       Anytime the employee reports to his headquarters (and returns), the status code "H" is to be designated. The round trip
                                        home to headquarters, mileage for those dates coded with "H" will be deducted from the total mileage to calculate the net
                                        business miles at the end of each month.

     * SPECIAL NOTICE FOR PICKUP TRUCKS:

                Although the M-805 is required for pickup trucks used as staff vehicle assignments, the payroll usage for pickup trucks is to be reported in hours as
                required by policy in the Highway maintenance Foreman's Manual, Section 1-4.
M-805       (7-04)                                                                                                                                                                                   ASSIGNED OPERATOR DATA
                                                                                                                                                                                         Name
                                                   RECORD OF EQUIPMENT OPERATION                                                                                                         Residence (city)
District / Organization Code           Equipment Number                Vehicle Make                          Vehicle Type                                License Number                  Round Trip Mileage
                                                                                                                   Sedan              SUV                                                (Home to Headquarters)
                 0900                                                                                              Station Wagon
                                                                                                                   Van
                                                                                                                                      Pickup Truck


                               DESTINATION                 ODOMETER READINGS            TOTAL        TRAVEL                                                                                                    STATE PROJECT NUMBER
  DATE                                                                                  MILES        STATUS                           NAME OF OPERATOR                                    COST
                       FROM                   TO           START           STOP       OPERATED        F or H                                                              ORG.   ALLOT    FUNC.      Sys.     S.R. or W.O.   Spur   Pha.   Section
                                                                                                 -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -                                                                        0900    719      9829
                                                                   -                             -
                                                                   -                             -
                                                                   -                             -
                                                                   -                             -
                                                                   -                             -
                                                                   -                             -
                                                                   -                             -
                                                                   -                             -
                                                                                       Total Miles   Total # "H"   Total Home Miles                  Total Field Miles       Total Days Used

                                                                                           0             0                  0                               0                      0
                                                          Operated for PENNSYLVANIA DEPARTMENT OF TRANSPORTATION
                   I hereby certify that the information above is correct and that this equipment has been used only in the fulfillment of my duties
                 for the Commonwealth of Pennsylvania.
                                                                                       OPERATOR'S SIGNATURE                                                                                                          DATE


                                                                                      SUPERVISOR'S SIGNATURE                                                                                                         DATE
                                  ACCIDENTS INVOLVING MAINTENANCE AND AUTOMOTIVE EQUIPMENT


Scope:             The following applies to all accidents involving Department motor vehicles or equipment (except aircraft) either
                   on or off the highway, regardless of how minor the injury and/or damage involved.

Policy:            After any accident, however minor, involving Department equipment or a motor vehicle (either on or off the
                   highway), the operator and the operator’s immediate supervisor are required to report that accident in the
                   manner prescribed below.

An accident involving Department equipment or motor vehicles which results in a fatality, serious personal injury and/or property damage over
$20,000.00 shall be the subject of an immediate investigation. The operator concerned shall be immediately suspended from operating
Department equipment/motor vehicles until such time as the accident is investigated and the District Engineer/District Administrator (Chief
Engineer for Central Office vehicles) approves reinstatement of operator privileges.

Responsibility:

          1.       OPERATOR OF VEHICLE/EQUIPMENT INVOLVED IN ACCIDENT

               o   Notify State or Local Police (or the Capitol Police if within the Capitol Complex) and request an investigation
                   of the accident. IF outside the Commonwealth, request an investigation by Local Police.

                   Exception:        A State or Local Police investigation is not required when all four of the following
                                     Conditions are met:

                                     a.   An accident involves Department equipment only and

                                     b.   involves no personal injury or fatality and

                                     c.   damages are less than $2,000.00, and

                                     d.   the vehicle does not have to be towed away.

               o   Prepare report and notify immediate supervisor as specified below.

          2.       OPERATOR-EMPLOYE’S SUPERVISOR

               o   Prepare and submit the written reports as specified in the procedure below.

          3.       ALL DEPARTMENT ORGANIZATIONS

               o   Ensure vehicle registration card, No-Fault Insurance card, at least
                   three (3) blank Forms STD-541 (Automobile Accident or Loss Notice, altered
                   For PADOT use), one (1) blank Form P6175 (Preliminary Accident Report),
                   Form AA-600 (Traffic Accident Report).
                   Form 614 (Operator’s Daily Report for Mobile Equipment), PADOT
                   Publication 22 and an official Transportation map are in each motor vehicle,
                   e.g., automobiles, trucks, etc. (does not include construction equipment)
                   at all times.

ACCIDENTS INVOLVING MAINTENANCE AND AUTOMOTIVE EQUIPMENT

Procedure

          1.       OPERATOR/EMPLOYEE


                   o   If an accident results in a serious injury, or fatality to a non-Department employee
                       or property damage over $10,000.00, report the details at once by telephone to
                       the Department of General Services, Bureau of Risk and Insurance Management.
                       During normal hours, call (717) 787-4987; at other times, call the Capitol Police at
                       (717) 787-3199. Collect calls will be accepted.

                   o   Immediately prepare Form P-6175 (Preliminary Accident Report) and by telephone,
                       relay the information to your supervisor.
amage over
rating
or (Chief

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:12/1/2011
language:English
pages:4