RDAC - Regional Driving Assessment Centre - ASSESSMENT APPLICATION FORM

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How do I apply?

If you have difficulty completing this application form, please contact the Assessment Centre for assistance.

To pay

When you have completed this form you can pay online by credit card. Payment details can be found in section E at the bottom of this form.

PDF form

If you wish to pay by cheque, download the PDF below. When you have completed this form you can print and post it with a cheque.

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Please give as much information as possible. For example: Are your limbs affected by restricted movement or lack of strength? If so, which ones?

Do you easily get tired or have problems with coordination, etc?

If you know the name of your medical condition or disability (e.g. cerebral palsy), Please write this here. If you have a non- specific medical condition or disability, please give as much information as you can, (e.g. back problems or problems with concentration).

ASSESSMENT APPLICATION FORM

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Form

Title

Mr Mrs Miss Ms Dr Other

Full Name

Address

Postcode

Telephone

Mobile

Date of Birth e.g. date / month / year

Driver No

Please complete this application form with as much detail as possible. The information you give will help us to plan for your assessment.

Which Assessment Centre would you like to attend?

SECTION A — ABOUT YOU

1. Occasionally people cancel appointments at short notice. Would you like us to tell you about last minute cancellations if it would mean an earlier appointment?

2. What kind of medical condition or disability do you have?

3. Please describe how your medical condition or disability affects you?

4. How long have you had this medical condition or disability?

5. What medication, (if any) do you take?

6. Can you walk at all?

7. Do you ever use a wheelchair or scooter?

If NO, please move on to question 11.

8. Do you ever use your wheelchair or scooter at home?

9. Do you ever use your wheelchair or scooter outside?

10. Can you transfer from your wheelchair or scooter into a vehicle without help from others?

11. Are you in receipt of the Higher Rate Mobility Component of the Disability
Living Allowance?

or the Mobility Supplement of the War Pension?

12. Is your condition the result of an accident?

If yes please provide further information.

SECTION B — YOUR ASSESSMENT

Our Centres offer five assessment and advice services. The information below will help you decide which of these is best for you. They each vary in how long they take and a different fee is charged for each service. A full report is prepared after each service.

a) Driving Ability Assessment

If you currently have a full licence, this assessment looks at both your ability to control the vehicle and to deal with traffic and other road users. It is for people such as those who have had a head injury, or a stroke or who have dementia. It is advisable to bring another driver to accompany you on the day of the assessment.

b) Driving Ability Assessment (Learner driver with Provisional licence)

This assessment is for people who are concerned about beginning to learn to drive, who are experiencing problems with driving tuition or who have learning difficulties.

c) Specialist Vehicle Assessment for drivers

This assessment is for people who need high technology solutions, for instance those who need to drive from a wheelchair. This type of assessment will be suitable if you cannot transfer from your wheelchair or if you cannot stow your wheelchair without help. We will give you the opportunity to try out equipment in an adapted Chrysler Voyager. Please note that cars can also be fitted with high technology equipment. To undertake this type of assessment you will require a valid driving licence, which can be either Full, Provisional, or a Provisional Disability Assessment Licence. The assessment looks at both your ability to control the vehicle and to deal with traffic and other road users.

d) Advice on Adaptations for Cars

This service is for people who have a physical disability and who need advice on car adaptations but who do not need to drive from a wheelchair. We will give you an opportunity to try out equipment in our vehicles.

e) Passenger/Carer Assessment

This service is for passengers who have difficulty getting in and out of a vehicle. The assessment explores a range of options including the use of specialist transfer equipment and a wheelchair accessible vehicle. This service may also benefit carers who are experiencing difficulty assisting in the transfer of their clients.

1. Which type of assessment do you want to apply for?

If you are unsure which assessment you require, please contact the Centre.

2. Have you attended an assessment before? If so, please give details.

3. Would you like us to send you a list of accommodation in and around our location?

We can provide information and assistance with completing forms such as Disability Living Allowance, Attendance Allowance, Motability or Blue badge applications.

If you require this service, please tick the box below, and our Information Officer will contact you before your assessment.

4. Do you need any advice on Benefits?

5. Do you have any other special requirements during your visit

6. Do you require the services of an interpreter?

If Yes, Which language?

If you want an assessment as a driver, please go to Section C
If you want an assessment as a passenger, please go to Section D

SECTION C — DRIVING LICENCE DETAILS

1. Do you have a valid driving licence?

2. Licence valid dates:

3. What type of vehicle do you drive at present?

4. Transmission:

5. Any Adaptations?

6. Does the DVLA know about your present condition or disability?

Please note it is your responsibility to inform the DVLA if you have a disability which is likely to affect your driving.

7. IF YES, when did you inform the DVLA?

8. Has a Doctor advised you against driving?

9. Please give the name and full contact details of your Doctor

10. Please provide any additional information which will enable us to assist you with your assessment

SECTION D

1. To help us plan our services, could you tell us how you heard about the Assessment Centre?

Been before	Forum website	Disability group
Mobility Centre	Doctor	Solicitor & Insurance comp
Driving Instructor	Social Worker/Social Services	DVLA
Publications and media	Friends or relations	Therapist
Garages/Modification firm	Other Charity	RDAC website

Other - please specify:

2. As part of our aim to reach everyone in the community, it would help us if you could tick one of these boxes for monitoring purposes.

White	British	Irish
White and Black Caribbean	White and Black African	White and Asian
Indian	Pakistani	Bangladeshi
Caribbean	African	Chinese

Other - please specify:

Prefer not to say

CONSENT

This section MUST be completed and must NOT be altered in any way.

1. Do you grant permission for details of your assessment to be discussed with a third party such as a family member, case worker, etc?

2. Please give name

3. I authorise my Doctor(s) and/or Specialist(s) to release reports to the Assessment Centre about my medical condition?

4. I authorise the Assessment Centre to release medical information to my Doctors and/or Specialists about the outcome of my case. (This is to enable your Doctor to advise you about fitness to drive)

The Data Protection Act 1998 requires us to seek your written consent to our processing the information provided by you on this form. Some of this information may be given to a third party for the purpose of finding out users views about the service provided by the Assessment Services or to specialists i.e. driving instructors or approved adaptation conversion firms who may be assisting you following your assessment. Only occasionally do we need to do this and it may well not apply in your case. We NEVER under any circumstances release information which is not relevant to your fitness to drive or discuss your personal details. Your signature will be taken to mean that you have given that consent.

Under the Data Protection Act you have the right to enquire, in writing, what personal information the Assessment Service is holding about you and, subject to a few limited exceptions, to be supplied with a copy of this information.

DECLARATION

I declare that I have checked the details I have given on this form and that to the best of my knowledge, they are correct.

You will be asked to sign the printed version of this form before your assessment can take place.

Thank you for taking time to complete this application form. We aim to let you know the date of your assessment within two weeks of receiving this form.