Computer-Based Driving Evaluation Form
Please complete this form to assess driving readiness and abilities using the computer-based evaluation system.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently hold a valid driving permit or license?
*
Yes
No
Do you have any medical or vision conditions that may affect your driving?
*
No
Yes (please specify below)
If yes, please describe your medical or vision condition(s):
Self-Assessment: Rate your confidence in the following driving skills.
*
Rows
Not Confident
Somewhat Confident
Very Confident
Understanding road signs
1
2
3
Judging distances
4
5
6
Reacting to hazards
7
8
9
Maintaining lane position
10
11
12
Using mirrors effectively
13
14
15
Evaluator Assessment: Please rate the participant on the following abilities.
*
Rows
Below Average
Average
Above Average
Attention and concentration
16
17
18
Reaction time
19
20
21
Decision making
22
23
24
Visual perception
25
26
27
Hand-eye coordination
28
29
30
Overall Driving Evaluation
*
1
2
3
4
5
Evaluator's Comments and Recommendations
Participant Signature (if required)
Submit Evaluation
Submit Evaluation
Should be Empty: