Disability Driving Assessment Form
Use this form to evaluate driving-related abilities, accessibility needs, and overall driving suitability for a disability driving assessment.
Applicant and Assessment Overview
Applicant Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
*
Phone
Email
Text Message
Other
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Purpose / Reason for Evaluation
*
Driving Function and Accessibility Assessment
Driving-related functional abilities
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable
Steering control
1
2
3
4
5
Pedal use
6
7
8
9
10
Turning head/neck to check blind spots
11
12
13
14
15
Transferring in/out of vehicle
16
17
18
19
20
Using vehicle controls
21
22
23
24
25
Maintaining posture/sitting tolerance
26
27
28
29
30
Mobility aid or driving adaptation used
None
Cane
Walker
Wheelchair
Hand controls
Steering aid
Pedal modification
Other
Vision, Cognition, and Recommendation
Vision-related driving concerns
*
No concern
1
2
3
4
Severe concern
5
1 is No concern, 5 is Severe concern
Attention and reaction concerns
*
No concern
1
2
3
4
Severe concern
5
1 is No concern, 5 is Severe concern
Decision-making concerns
Please Select
No concern
Mild concern
Moderate concern
Significant concern
Severe concern
Overall assessor recommendation
*
Fit to drive
Fit with vehicle modifications
Needs further evaluation
Not currently fit to drive
Follow-up required
Submit Assessment
Should be Empty: