Driver Safety Diagnostic Evaluation Form
Use this form to evaluate a driver’s safety habits, recent risk factors, and areas for improvement.
Driver Profile
Full Name
*
First Name
Middle Name
Last Name
Age Range
*
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Contact Phone or Email
*
Vehicle Type Driven Most Often
*
Please Select
Sedan
SUV
Pickup Truck
Van
Motorcycle
Commercial Vehicle
Bus
Other
Years of Driving Experience
*
Less than 1 year
1-2 years
3-5 years
6-10 years
11-20 years
More than 20 years
Primary Driving Environment
*
City
Suburban
Highway
Mixed
Driving Habits and Safety Behaviors
How often do you drive?
*
Daily
Several times a week
Weekly
A few times a month
Rarely
Never
Average weekly mileage or driving hours
How often do you wear your seat belt while driving?
*
Always
Most of the time
About half the time
Rarely
Never
How consistently do you follow posted speed limits?
*
Rarely follows
1
2
3
4
5
6
7
8
9
Always follows
10
1 is Rarely follows, 10 is Always follows
How often do you use your phone while driving?
*
Never
Only when stopped
Hands-free only
Occasionally
Frequently
How well do you manage fatigue before driving?
*
Poorly managed
1
2
3
4
5
6
7
8
9
Well managed
10
1 is Poorly managed, 10 is Well managed
How consistently do you maintain a safe following distance?
*
Too close
1
2
3
4
5
6
7
8
9
Always maintains safe distance
10
1 is Too close, 10 is Always maintains safe distance
Recent Risk and Incident Review
Any traffic violations, near-misses, collisions, or unsafe driving incidents in the past 12 months?
*
Yes
No
Number of incidents in the past 12 months
Common contributing factors
Distraction
Fatigue
Speeding
Weather
Unfamiliar routes
Time pressure
Other
Vehicle maintenance status
*
Up to date
Due soon
Overdue
Not sure
Recurring conditions that affect safety
Poor visibility
Night driving
Heavy traffic
Frequent long trips
Medical or physical fatigue
Stress
Other
Diagnostic Ratings and Self-Assessment
Safety Readiness Ratings
*
Rows
1 - Strongly Disagree
2 - Disagree
3 - Neutral
4 - Agree
5 - Strongly Agree
I remain alert while driving
1
2
3
4
5
I can quickly identify hazards
6
7
8
9
10
I react promptly to changing situations
11
12
13
14
15
I am confident navigating heavy traffic
16
17
18
19
20
I feel confident driving at night
21
22
23
24
25
I feel confident driving in adverse weather
26
27
28
29
30
I consistently comply with road rules
31
32
33
34
35
Overall Safety Self-Rating
*
1
2
3
4
5
Areas Needing Improvement
Alertness
Hazard perception
Reaction time
Heavy traffic navigation
Night driving confidence
Adverse weather confidence
Road rule compliance
Other
Additional Self-Assessment Comments
Recommendations and Follow-Up
Training topics needed
*
Defensive driving
Distraction reduction
Fatigue management
Night driving
Wet-weather driving
Vehicle upkeep
Other
Preferred follow-up format
*
Email summary
Coaching call
Refresher course
No follow-up needed
Additional comments or concerns
Submit Evaluation
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