Senior Driver Assessment Form

Senior Driver Assessment Form
Comprehensive evaluation of senior drivers’ abilities and safety for continued driving.
Driver’s Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you wear corrective lenses while driving?
Have you experienced any of the following in the past year? (Select all that apply)
Other
How often do you drive?
Have you had any accidents or near-misses in the past 2 years?

Assessment of Driving Skills

Rows	Needs Improvement	Adequate	Excellent
Observation and reaction to traffic
Ability to follow road signs and signals
Maintaining lane position
Speed control
Judgment in complex situations
Use of mirrors and checking blind spots

Vision and Hearing Assessment (Rate each)
Assessor’s Comments and Recommendations
Signature of Assessor (to confirm assessment completion)
Powered by Jotform SignClear
Should be Empty:

Select theme: