OT Driver Assessment Information & Consent Form
Client Details
First Name
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Last Name
*
Date of birth
*
Next of Kin /Carer Details
Next of Kin / Carer Full Name
*
Next of Kin / Carer Phone Number
*
Next of Kin / Carer Email
*
Client Medical Details
Medical Diagnoses (including date of diagnosis)
*
Medications currently taken (please note name and dosage)
*
Side effects of medications currently taken
*
GP/Specialist Details
*
Please provide name, practice name and email contact. If you don't have a regular GP just provide the practice name and email contact.
Client Driving History
What kind of class of licence do you hold?
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C - Car Licence
LRN - Learner
Provisional Licence 1
Provisional Licence 2
R - Rider Licence
RE - Restricted Rider Lience
LR - Light Rigid Licence
MR - Medium Rigid Licence
HR - Heavy Rigid Licence
HC - Heavy Combination Licence
MC - Multi-Combination Licence
Please tick all that apply.
Do you have concerns about your ability to drive safely?
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Yes
No
Unsure
Have you been involved in a car accident in the past 5 years when you were the driver of the car?
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Yes
No
Have you received any driving infringements in the past 5 years?
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Yes
No
Have you received any driving convictions in the past 5 years?
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Yes
No
Client's Vehicle Details
What is the make and model of the car you currently drive or intend to drive?
*
Please describe the kind of car you currently drive or intend to drive
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Automatic
Manual
Power Steering
Modified vehicle
Unknown
Provision of Information
If you haven't provided us with this information already, please attach a copy of your Driver's Licence and a TMR Medical Certificate if you have an 'M' condition on your Licence or if you have a medically suspended Licence.
*
Browse
Consent
I agree to participate in an off-road driver assessment, which includes: 1) a clinical interview regarding my driving history and experience with driving; 2) a clinical interview regarding my medical history and current treatment; 3) a visual, physical and cognitive screen; and 4) a test of my road law knowledge
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Yes
No
A Driver's Assessment will not be scheduled if you choose 'no'.
After the off-road assessment, I also agree to complete an on-road assessment while driving in the car, which includes: 1) the Occupational Therapist documenting the situations that occur during the drive whilst seated in the rear passengers seat; and 2) a licensed Driving Instructor sitting in the front passengers seat, with access to dual controls.
*
Yes
No
A Driver's Assessment will not be scheduled if you choose 'no'.
The Occupational Therapist will write a report based on the information obtained during the off-road and on-road assessments. I consent to this report being sent to one or more of the following people: 1) my doctor; 2) the Department of Transport and Main Roads; 3) my insurer (including NDIS); and 4) my next of kin.
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Yes
No
A Driver's Assessment will not be scheduled if you choose 'no'.
Signature
Full name of the person providing consent
*
Relationship to the client (if not the client)
Email of the person providing consent
*
Your Signature
*
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Date of consent
*
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