Driving Rehabilitation Pre-Screen

Pre-screen inspection template for documenting vision, reaction time, cognition, and physical function to determine whether a driver rehabilitation evaluation, on-road assessment, or referral is needed.

Screening Instructions and Referral Basis

• Referral source documented
  Record who initiated the driving pre-screen (e.g., physician, therapist, family, self-referral, employer, insurer).
• Physician order or authorized referral on file
  Confirm whether a physician order or other authorized referral is present when required by local policy or program protocol.
• Primary concern for driving safety documented
  Select the main concerns prompting the screen.
• Current driving status documented
  Record the individual's current driving status.

Vision Screening

• Distance visual acuity recorded for each eye and both eyes
  Enter measured distance acuity values for right eye, left eye, and both eyes with correction status noted.
• Visual field concern identified
  Indicate whether there is evidence of restricted visual field, neglect, hemianopsia, or other field loss affecting driving safety.
• Depth perception and contrast sensitivity adequate for driving tasks
  Assess whether the individual demonstrates functional depth perception and contrast awareness for lane position, curb detection, and hazard recognition.
• Glasses or corrective lenses available and used as prescribed
  Confirm whether the individual arrived with the required corrective lenses and uses them consistently for driving.
• Vision-related referral needed
  Select the recommended next step if visual screening is not sufficient for driving clearance.

Reaction Time and Attention

• Simple reaction time measured
  Record the measured reaction time from the screening task.
• Responds appropriately to visual and auditory cues
  Assess whether the individual can detect and respond to cues in a timely and consistent manner.
• Divided attention during dual-task activity
  Rate the individual's ability to maintain performance while managing a secondary task.
• Reaction time concern requires further evaluation
  Choose the recommended next step based on screening findings.

Cognition and Judgment

• Orientation to person, place, time, and situation
  Rate orientation based on interview and screening observations.
• Short-term memory adequate for driving-related instructions
  Determine whether the individual can recall and follow brief driving-related directions.
• Judgment and insight into driving risk
  Rate the individual's awareness of limitations and ability to make safe driving decisions.
• Cognitive screening result documented
  Enter the name of the screening tool used and the score or summary result, if applicable.
• Cognition-related referral needed
  Select the recommended next step based on cognitive screening findings.

Physical Function and Mobility

• Upper extremity range of motion supports steering and controls
  Assess whether shoulder, elbow, wrist, and hand motion appear sufficient for steering, signaling, and control use.
• Lower extremity function supports pedal use
  Assess whether lower extremity strength, coordination, and range of motion support safe accelerator and brake use.
• Transfers and seated posture adequate for vehicle operation
  Determine whether the individual can maintain safe seated posture and perform vehicle transfers if needed.
• Adaptive equipment or vehicle modification needed
  Select whether adaptive equipment or vehicle modifications should be considered.

Disposition, Findings, and Sign-Off

• Screening disposition
  Select the final recommendation based on the pre-screen findings.
• Corrective action or follow-up plan documented
  Document any follow-up actions, referrals, restrictions, or education provided.
• Inspector signature
  Signature of the clinician or evaluator completing the pre-screen.