Admin SOP #32 Attachment 5

MOTOR VEHICLE ASSIGNMENT AND USE AUTHORIZATION FORM

CHANGE / CANCEL

Instructions: For employee that is being assigned a different vehicle, please complete Sections 1, 2, and 4-7. For an employee that is being transferred to another Division, Section, or Location, please complete Sections 1, 2 (if necessary), and 3-7. For employee that no longer has a vehicle assigned, please complete Section 1 and 7. Completed forms are to be sent to the DNR Fleet Coordinator for submission to DOAS Office of Fleet Management for approval.

Section 1 – Employee Information

Last Name: ______First Name: ______Employee ID#: ______

Division / Section / Location: ______

CHANGE (Employee being assigned a different vehicle) CANCEL (Employee no longer assigned a vehicle)

Section 2 – Change of Vehicle Information

Current Decal Number: ______New Decal Number: ______

Section 3 – Employee Transfer

From: Division / Section / Location: ______

To: Division / Section / Location: ______

Section 4 – Assigned Vehicle Use: MARK ONLY ONE “YES”

1.  Does the State employee drives 14,000 State business miles, in order to routinely YES NO

conduct State business? (This cannot include Commuting Miles)

2.  Is the vehicle used to transport equipment that is too large or heavy, or has special YES NO

Features that makes it impractical to be transferred between vehicles or between a

vehicle and a fixed location?

3.  Is the vehicle required to be driven to sites or under conditions that would endanger YES NO

privately owned vehicles?

4.  Does the employee's position require the individual to perform duties of a YES NO

sworn/POST certified/registered law enforcement officer AND having a vehicle is essential

for the employee to carry out his/her job functions?

Section 5 – Overnight Vehicle Use: MARK ONLY ONE “YES”

Note: Only drivers that qualify for Assigned Vehicle Use (above) can apply for Overnight Use

1.  The position requires the employee to perform the duties of a YES NO

sworn/POST certified/registered law enforcement officer, and the vehicle assigned

to the employee is specially equipped for law enforcement purposes, and having the

vehicle is essential for the employee to carry out their job functions?

2.  Does the employee work out of his/her home and travel to different work sites YES NO

as part of routine duties?

3.  Is there no overnight security at the employee's work site where there is evidence of YES NO

vandalism, and security cannot be obtained for a modest cost nearby?

4.  Does the employee regularly travel directly to remote sites (of sufficient distance for the YES NO

employee to be on travel status) from his or her home, rather than reporting daily to a

central worksite/office?

5.  As a condition of employment, is the driver required to regularly respond directly to the YES NO

scene of emergencies associated with this position on a 24/7 basis? (Refer to Policy 10,3.3.1

for Vehicle Restrictions/Conditions)

On-call staff must maintain documentation of the number of times they are called to a scene on a month-to-month basis on the Emergency Call-Out Log (Attachment 6). Only those individuals who have 12 call-outs per year will be authorized for overnight use on a routine basis. This information must be documented on the individual DOAS MV-1 form and submitted to OFM.

Section 6 – Employee Certification

I certify the above listed information is complete and accurate for the purpose of this request.

Employee’s Signature______Date ______

Section 7 – Agency Recommendation

Employee is recommended for authorization of individual

assignment of a vehicle per Section 2. YES NO

Employee is recommended for authorization of overnight

use of the vehicle on a routine basis per Section 3. YES NO

Agency Head or Designee Signature ______Date ______

Agency Approved Signature ______Date ______

MV1 Update Form

03/2015 Page 2 of 2