Motorbike Assessment

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Personal

Title
Name * First Last
Gender
Date of Birth *
Address *
Street Address Address Line 2 City County Postcode
Home Number *
Mobile Number
Email *
Are you in receipt of the Higher Rate Mobility Component of the Disability Living Allowance? *
Yes No
Are you in receipt of the Mobility Supplement of the War Pension? *
Yes No

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Medical Conditions

Do you have any medical conditions/disabilities? *
Yes No
What kind of medical conditions/disabilities do/did you have?
Stroke Head Injury Amputation MS Parkinsons Huntingtons Cerebral Palsy MND Arthritis Spinal Bifida Dystrophy Dementia Spinal Cord Injury Other
What other medical condition/disability do/did you have?
How long have you had your medical condition/disability?
Please describe in as much detail as possible how this affects/affected you (if at all)?
Do you have no use in...?
Neck Spine Left arm Right arm Left hand Right hand Left leg Right leg Left foot Right foot
Do you have limited use in...?
Neck Spine Left arm Right arm Left hand Right hand Left leg Right leg Left foot Right foot
Do you take any medication?
Yes No
What medication do you take?
How does the medication affect you?
Does your medication affect your driving?
Yes No

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Current Ability

Can you walk unaided?
Yes No
How far can you walk unaided?
Do you use any of the following mobility aids?
1. Manual wheelchair (self propelled)
  1. What is the make and model of your Manual wheelchair (self propelled) (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your Manual wheelchair (self propelled)?
    Indoors Outdoors
2. Manual wheelchair (attendant propelled)
  1. What is the make and model of your Manual wheelchair (attendant propelled) (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your Manual wheelchair (attendant propelled)?
    Indoors Outdoors
3. Powered wheelchair
  1. What is the make and model of your Powered wheelchair (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your Powered wheelchair?
    Indoors Outdoors
4. 3 wheel scooter
  1. What is the make and model of your 3 wheel scooter (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your 3 wheel scooter?
    Indoors Outdoors
5. 4 wheel scooter
  1. What is the make and model of your 4 wheel scooter (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your 4 wheel scooter?
    Indoors Outdoors
6. Crutches
  1. What is the make and model of your Crutches (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your Crutches?
    Indoors Outdoors
7. Walking frame
  1. What is the make and model of your Walking frame (if known)?
  2. Can you transfer into a vehicle without the help of others all the time?
    Yes No
  3. Where do you use your Walking frame?
    Indoors Outdoors

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Booking

Have you attended an assessment with the RDAC before?
Please give a reference number (if known)
Please give any dates you cannot make for an assessment over the next 4 months
Which centre would you prefer to attend?
Oxford Cannock Birmingham Hull Northampton
Would you take an appointment at short notice (one day notice minimum)?
Yes No
Would you like us to send you a list of accommodation around the area of selected assessment centre?
Yes No
Do you have any special requirements during your visit?

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Driving Licence

Do you have a valid driving licence?
Yes No
What type of licence do you hold?
If Provisional or PDAL, are you currently having, had tuition or have you never driven?
Does your driving licence entitle you to drive...?
Manual car Automatic car LGV PDV Motorbike
If full licence, are you driving at present?
Yes No
If you are not driving at present, when did you last drive?
Licence valid from
Licence valid to
Licence Number
Have you informed the DVLA of your medical condition/disability?
Yes No N/A
Date DVLA informed?
You are legally required to notify the DVLA if you have a condition likely to affect your ability to drive or if you have any adaptations fitted to your vehicle. If you are concerned about this, please ring the centre for further information.
Has your doctor advised you against driving?
Yes No Take an Assessment

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Vehicle Details

Which vehicles do you have?
What is the vehicle make and model?
Transmission type?
Year of registration
Are there any adaptations currently on this vehicle?
Yes No
Please list the adaptations currently on your vehicle
In your opinion, are you able to operate the standard controls of a motorbike?
Yes No
If not, what restrictions do you have?
Are you able to climb aboard and sit on a motorbike unaided?
Yes No
When stationary, can you support the weight of the motorbike with one leg?
Yes No

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GP Details

GP Name *
Address
Street Address * Address Line 2 City * County Postcode *
GP telephone number
Declaration

I authorise my Doctor(s) and/or Specialist(s) to release reports to the RDAC about my medical condition(s) / disabilities and I authorise RDAC to release medical information to my Doctor(s) and/or Specialist(s) about the outcome of my case. This is to enable your Doctor to advise you about fitness to drive.
Enter your full name in capitals *

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Other

If you believe there is any other information that could help us with your assessment or any other matters, please write them here.
If you require a home visit, please give details of suitable times below.
Do you intend to use this report for legal, insurance, case management or employer purposes?
Yes No
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.
Do not wish to respond White - British White - Irish White - Other Black - Carribean Black - African Black - Other Asian - Indian Asian - Pakistani Asian - Bangladeshi Asian - Chinese Mixed - White & Black Carribean Mixed - White & Black African Mixed - White & Asian Mixed - Other Other
Consent for DVLA
Due to the data protection act, the RDAC is unable to contact the DVLA regarding your assessment, limiting the range of information available to assessors. It also stops the RDAC from verifying your licence status before the day of assessment, which if not valid can mean we are unable to complete your assessment, resulting in your fee being non refundable.

By signing this section you are providing the RDAC with written consent to:
1. Check your licence status and entitlement to drive.
2. To send to and receive from DVLA any personal information and reports pertaining to your assessment.
Enter your full name in capitals
Data Protection Act

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 user's views about the service provided by the Assessment Services or to specialist 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 RDAC is holding about you and, subject to a few limited exceptions, to be supplied with a copy of this information.

Enter your full name in capitals
Declaration

I declare that I have checked the details I have given on the enclosed questionnaire and that to the best of my knowledge they are correct.

Enter your full name in capitals
Consent

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

Motorbike Assessment

Personal

Medical Conditions

Current Ability

Booking

Driving Licence

Vehicle Details

GP Details

Declaration

Other

Consent for DVLA

Data Protection Act

Declaration

Consent