Driver Write-Up Form for NEMT: Late Pickups, Securement, and Rider Complaints

A write-up at a NEMT company can start with a broker’s email, a rider’s call, or something you saw yourself: a pickup 40 minutes late, a wheelchair strap left loose, a driver texting behind the wheel. The broker wants to know what you did about it, and the driver deserves to know where they stand. This form gives you one page for both, with a part for the broker steps that NEMT work adds.

How to use this template

1. Write it the same day. Pull the trip record with scheduled and actual times, the GPS trail, any camera video, and the broker’s notice while they are easy to find. If the event came in as a complaint, log it first in the complaint log and copy its number into Part 1.
2. Write facts, not labels. “Arrived 11:42 for an 11:15 pickup, per the trip log” holds up. “Always late” does not. Brokers judge your answer on records: CareOregon’s manual treats every grievance as potentially valid and preventable until documentation proves otherwise.
3. Hear the driver before you decide. Ask what happened and write the answer in the driver’s words in Part 4. A tight route or a broken lift is a fix for you, not a warning for the driver.
4. Pick the step your handbook names. Section 13 of the driver handbook lists your steps, such as coaching, written warning, suspension, and firing, and what can skip a step. Use the same steps for every driver.
5. Settle the broker question in Part 5. Some events must go to the broker at once, and the broker may hold the driver off its trips no matter what you decide. The section below lists the common rules.
6. Make the signature a receipt. The driver signs that they received a copy, not that they agree. If the driver will not sign, a witness writes that down.
7. Give a copy and file the original. Connecticut requires the copy within 1 business day. File the original in the driver’s personnel file, and note any retraining in the driver training log.

Use this form for one event. Scheduled reviews belong on the driver evaluation form, and a crash or injury also needs an incident report.

The template

Part 1: Driver and write-up details

Field	Write the entry here in pen
Driver’s full name
Badge or employee number
Supervisor writing this form
Date written
Date and time of the event
Broker or health plan for the trip
Broker trip number and complaint number
Vehicle number
Step taken (documented coaching, written warning, final written warning, suspension)
Earlier write-ups on the same problem (dates)

Part 2: What happened

Problem	Check	Rule it broke (handbook section or broker clause)
Late pickup or late drop-off
Missed pickup, or left before the wait time ended
Securement, lift, or seat belt step skipped
Phone use while the van was moving
Rider or facility complaint forwarded by a broker
Rude, unsafe, or unwanted conduct toward a rider
Wrong level of help (curb-to-curb, door-to-door, hand-to-hand)
Pre-trip inspection skipped or not recorded
Trip times, odometer readings, or signatures wrong
Rider information shared or left where others could see it
Other

Part 3: The facts

Field	Write the entry here in pen
Scheduled time and actual time, from the trip record
What the rider, facility, or broker reported, in their words
What the records show (GPS, camera, inspection sheet, photos)
Witnesses and how to reach them
Harm or risk to the rider
Documents attached

Part 4: The driver’s side

Field	Write the entry here in pen
Date the driver was asked for their account
The driver’s account, in the driver’s words
Anything outside the driver’s control (route, dispatch, vehicle, rider)
Written statement from the driver attached (yes or no)

Part 5: Broker and trips

Field	Write the entry here in pen
Does a broker contract require notice of this event (yes or no, which clause)
Broker told (date, how, and the person you reached)
Broker’s reference number
Driver held off that broker’s trips until (date)
Driver held off all trips while you review (yes or no, until when)
Retraining required before driving again (course and date done)
Broker’s decision (cleared, retrain, suspended, removed)

Part 6: What happens next

Field	Write the entry here in pen
What the driver will do differently
Retraining or ride-along, and the date it is due
Date you will check progress
What happens if it happens again

Part 7: Signatures

Field	Write the entry here in pen
Supervisor’s printed name, signature, and date
Driver: “I received a copy of this form. Signing does not mean I agree with it.” Signature and date
Driver: “If I disagree with anything in this form, I may write a statement giving my side. It will be kept with this form.” Initials
Driver declined to sign: witness’s printed name, signature, and date
Date a copy was given to the driver, and how

When the broker has to hear about it

Your write-up and the broker’s rules run side by side. A broker can hold or remove a driver whatever step you choose, and some events must reach the broker before you finish your own review. These rules were current as of October 2026.

• MTM Health. Its standard agreement, in the January 1, 2023 version Pennsylvania posts, requires immediate notice of any criminal investigation, charge, or proceeding against a driver, and of any conviction for a crime against a person, an alcohol-related driving offense, or a crime of moral turpitude (section 2.R). If you reasonably suspect a driver is under the influence, you must remove the driver from service at once and pay for a drug or alcohol test (5.F). MTM may deactivate or suspend any driver for safety, at a client’s request, or for other good cause in its sole discretion (5.H). The same agreement bars drivers from using a cell phone or texting device while driving (3.N). See MTM Health.
• Modivcare. Its 2025 compliance attestation requires you to notify Modivcare immediately of any accident, incident, or moving violation involving a driver or vehicle serving its trips, and to cooperate with its investigation. See Modivcare.
• Verida in Tennessee. In the BlueCare Tennessee provider manual effective October 1, 2026, Verida’s compliance officers watch drivers on the job and at the yearly road test. A driver who breaks the conduct standards gets a notice of non-compliance and may be sent to a coaching session or remedial training. A driver with more than 2 incidents, or who skips the remedial training, can no longer drive in Verida’s network. A driver who is arrested for, charged with, or convicted of a disqualifying offense must tell you at once, and you must tell Verida at once. The same standards allow phones only to answer a dispatcher’s call or make an emergency call. See Verida.
• Oregon. CareOregon’s provider manual (version 1.3, February 2024) is the template for the brokerages serving Columbia Pacific CCO, Health Share of Oregon, and Jackson Care Connect. It treats every grievance and incident as potentially valid and preventable until documentation proves otherwise. A brokerage may suspend a driver at once while it investigates improper conduct or harassment, and a driver suspected of harassing a member is suspended right away. You may challenge a suspension with a written appeal. See Ride to Care.

How to answer the complaint itself, with the proof brokers accept, is in broker rider complaints.

State personnel file rules that reach a write-up

A write-up becomes part of the driver’s personnel record, and several states give the driver rights over it. Three common ones are below. The main points: give a copy quickly, let the driver add their side, and keep the file after the driver leaves.

State	Copy to the driver	The driver’s side	Keep the file
Connecticut (Gen. Stat. 31-128b, 31-128e)	Within 1 business day of the discipline	The form must say clearly that the driver may submit a written statement. It stays with the file.	At least 1 year after the job ends
Massachusetts (G.L. c. 149, sec. 52C)	Notice within 10 days of adding it. A copy within 5 business days of a written request.	If you cannot agree on a fix, the driver’s written statement joins the record	3 years after the job ends, for employers with 20 or more employees
California (Labor Code 1198.5 and 432)	Within 30 calendar days of a written request, plus a copy of anything the driver signed, on request	Not set by these sections. Keep Part 4 anyway.	3 years after the job ends

Connecticut also lets an employee inspect and copy the file within 7 business days of a written request, and a former employee within 10 business days if they ask within a year of leaving. Massachusetts fines a violation $500 to $2,500. California sets a $750 penalty when you miss its deadline. The Part 7 lines on the driver’s own statement meet Connecticut’s rule and work in every state.

What a write-up cannot punish

Discipline the conduct, never the protected act. These federal rules apply whatever your state.

• Talking about pay and working conditions. The NLRB says covered employees have the right to discuss wages with coworkers, union or not, and an employer may not punish them for it. A rule that bans those talks, or requires your permission first, is itself unlawful. The same protection covers acting with coworkers on working conditions, such as a group complaint about split shifts or unpaid waits. It can be lost for egregiously offensive or knowingly and maliciously false statements.
• Complaining about discrimination or harassment. The EEOC lists filing a charge, complaining to a manager, answering questions in a harassment investigation, and asking for a disability or religious accommodation as protected. Most of these laws reach employers with 15 or more employees, and the equal pay law reaches employers with even one. The EEOC also says protected activity does not shield an employee from discipline for other, legitimate reasons.
• Reporting a work injury. OSHA’s injury reporting rule says you must not discharge or in any way discriminate against an employee for reporting a work-related injury or illness (29 CFR 1904.35). Section 11(c) of the OSH Act bars the same, and also protects a driver who files a safety complaint (29 CFR 1904.36).

If a driver’s complaint about pay or safety comes up during the meeting, write it down separately and look into it. Keep it out of the warning. For keeping drivers once the warning is done, see NEMT driver retention.

A privacy write-up is also a HIPAA record

When the problem is rider information, such as a manifest left on the dashboard or a rider’s name in a group text, the write-up does double duty. The HIPAA Security Rule requires covered entities and business associates to apply appropriate sanctions against workforce members who break their security policies (45 CFR 164.308(a)(1)(ii)(C)). The Privacy Rule requires a covered entity to apply sanctions for privacy violations and to document the sanctions it applies, and to keep that documentation 6 years (45 CFR 164.530(e) and (j)).

Check the Part 2 privacy box, name the policy section the driver broke, and keep a copy with your HIPAA records as well as in the personnel file. If rider information left your control, decide whether it is a breach and record it in the HIPAA breach log. Your sanction steps belong in the HIPAA policy.

If the write-up ends in a firing

The last write-up sometimes ends the job. Four things then happen fast.

1. Final pay. Federal law does not require a final paycheck right away, but some states do, so check yours. California, for example, makes wages due immediately when you discharge an employee (Labor Code 201).
2. Broker rosters. Take the driver off every broker account. MTM’s portal tips, linked from its Wisconsin provider page, tell you to contact your vendor account manager to remove a driver who no longer drives for you.
3. Rider data. Cut off broker portal, dispatch app, and email access the same day. HIPAA expects procedures for ending access when a job ends (45 CFR 164.308(a)(3)(ii)(C)).
4. Screening reports. If the decision rests on a background or driving record report from a screening company, the FTC requires a copy of the report and “A Summary of Your Rights Under the Fair Credit Reporting Act” before you act, and an adverse action notice after.

The full list, with final pay deadlines by state and the notices to hand over, is in the employee termination checklist.