OT Driver Assessment Information & Consent Form - Insurer Referral
Claimant Details
Name
*
Date of birth
*
Next of Kin Details
Next of Kin Full Name
*
Next of Kin Phone Number
*
Next of Kin Email
*
Claimant Medical Details
Medical Diagnoses (including date of diagnosis)
*
Medications currently taken (please note name and dosage)
*
Side effects of medications currently taken
*
Write 'none' if the claimant is not experiencing side effects
GP/Specialist Details
*
Please provide name, practice name and email contact.
Claimant Driving History
What kind of class of licence do you hold?
*
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.
What conditions/restrictions do you have on your Driver's Licence and/or TMR Medical Certifcate?
*
Write 'none' if you don't have conditions on your Driver's Licence.
Claimant's Vehicle Details
What is the make and model of the car or heavy vehicle you currently drive or intend to drive?
*
Please describe the kind of car you currently drive or intend to drive
*
Automatic
Manual
Modified vehicle
Road Ranger
Synchromesh
Unknown
Provision of Information
Please attach a copy of the Claimant's Driver's Licence and a TMR Medical Certificate clearing the Claimant to participate in the OT Driver Assessment.
*
Browse
If unsure please discuss with On The Move OT.
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
*
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; and 4) my next of kin.
*
Yes
No
A Driver's Assessment will not be scheduled if you choose 'no'. The questions in this section need to be verbally agreed to by the Claimant.
Signature
Full name of the person providing consent
*
Relationship to the claimant (if not the client)
Email of the person providing consent
*
Your Signature
*
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Type signature
Clear
Date of consent
*
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