Dash Cam Driver Safety Assessment Form
Use this form to record driver details, assess observed driving safety behaviors from dash cam footage, and note follow-up actions.
Driver and Trip Details
Driver Name
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vehicle Identifier / Plate Nickname / Fleet Unit Label
*
Route or Trip Context
*
Assessor / Observer Name
*
Safety Assessment
Overall driving safety rating
*
1
2
3
4
5
Driving behavior frequency
*
Rows
Never
Rarely
Sometimes
Often
Always
Speeding
1
2
3
4
5
Hard braking
6
7
8
9
10
Abrupt lane changes
11
12
13
14
15
Tailgating
16
17
18
19
20
Phone distraction
21
22
23
24
25
Seat belt use
26
27
28
29
30
Overall risk level
*
Low
Moderate
High
Notes and Follow-up
Observer Comments or Incidents Observed
Recommended Follow-up Action
*
No action needed
Coaching recommended
Reassessment needed
Supervisor review
Submit Assessment
Should be Empty: