CSMA 19 (11/25/2017)
By signing below I certify that I have observed the learning driver identified above performing the safe driving maneuver checked. In addition, I
certify that I am authorized to accompany the learning driver in accordance with Va. Code § 46.2-335.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of
perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
1. Basic Skills -
Is attentive, alert, aware of surroundings and traffic conditions,
follows instructions well, observes conditions in time to compete a
maneuver safely.
2. Starting -
Demonstrates ability to start engine, engages and uses
proper gear, demonstrates proper use of brake.
3. Backing - (DO NOT PRACTICE ON STREET WITH TRAFFIC)
Looks at mirrors, looks over both shoulders, uses brake and
accelerator well, controls vehicle while driving in reverse, backs
vehicle smoothly in a straight line without weaving.
4. Posture -
Sits upright, arms and legs are in easy reach of controls, adjusts
mirrors and seat to best position for vision and driving.
5. Gears -
Shifts gears or uses automatic transmission smoothly,
accelerates smoothly, changes gears smoothly, keeps eyes on the
road while shifting, shifts gears at correct speed.
6. Following -
Maintains proper distance and speed in traffic.
7. Right of Way -
Yields without hesitating when necessary, shows consideration of
pedestrians, attention to signals, makes proper use of right-of-way in
traffic, stops behind crosswalks.
8. Lanes -
Stays in proper lane, checks traffic before changing lanes, changes
lanes easily, does not change lanes excessively, does not straddle
lanes.
9. Overtaking/Passing -
Controls vehicle in proper lane while passing on multi-lane
street, judges distance, signals intention, accelerates
properly, uses horn if necessary
10. Intersection -
Is able to negotiate and drive through controlled and
uncontrolled intersections, reduces speed when approaching,
checks intersection traffic, controls vehicle, looks both ways.
11. Signs & Signals -
Observes and obeys stop signs and other signals, stops at
indicated place, proceeds to gain clear vision but stops again
if necessary.
12. Traffic Lights -
Observes the red, yellow, green traffic lights, interprets and
obeys the meaning of the light's color and the location on the
traffic light, comes to smooth stop in ample time, observes
crosswalks, starts promptly when light turns green.
13. Turns -
Makes proper signal of intention to turn, gets into proper lane,
reduces speed as required and completes turn satisfactorily.
14. Turn-about or U-turns -
Shows ability to perform U-turns, controls steering and
operates vehicle in close quarters, watches traffic, signals
correctly, changes gears and reduces speed and accelerates
properly, stops for traffic.
15. Parking -
Drives into a parking lot and parks vehicle, checks for any
traffic, signals when necessary, maintains proper speed,
parks within lines.
DRIVER INFORMATION
LEARNING DRIVER NAME (print) LEARNER’S PERMIT NUMBER
EXPIRATION DATE (mm/dd/yyyy)
DRIVER LICENSE NUMBER
LICENSED OBSERVING DRIVER CERTIFICATION
OBSERVING DRIVER SIGNATURE
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
DRIVER LICENSE NUMBER
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
DRIVER LICENSE NUMBER
I certify that at all times while holding a learner’s permit and operating a motor
vehicle, I have been accompanied by a licensed driver. I further certify that the
licensed driver was authorized under Va. Code § 46.2-325 to accompany me.
LEARNING DRIVER SIGNATURE
OBSERVING DRIVER SIGNATURE
LEARNER'S PERMIT NUMBER
DRIVER LICENSE NUMBER
By signing below I certify that I was the only person who observed the learning
driver identified above performing the safe driving maneuvers.
IN-CAR MANEUVERS
OBSERVATION RECORD
DRIVER/OBSERVER CERTIFICATIONS
Check box and sign name when maneuver is completed. If the same observing driver observes all the maneuvers, sign only the Driver/Observer
Certifications section.
SAFE DRIVING MANEUVERS
Purpose: Learning drivers age 18 and older who hold a learner’s permit but have not completed a Virginia approved driver training course and
qualifying home-schooled students use this form to verify the observation and completion of safe driving maneuvers before applying to
take the road skills test at DMV.
Instructions: Each maneuver must be checked and signed by the licensed driver who observes the learning driver while practicing the
maneuvers. Submit the completed form to any DMV customer service center to take the road skills test.
