Department of Consumer Affairs, Board of Occupational Therapy

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Older Californian Traffic Safety Task Force - Driver Rehabilitation Services Survey

1. Do you or the facility you work at currently provide driver rehabilitation services?
Yes  No

2. What is the name and address of your work facility or business?

3. What are the hours of operation of your facility or business?

4. Are you a certified Driving Rehabilitation Specialist?
Yes  No

5. How much training have you received in driver rehabilitation?
Less Than 1 Year
1-3 Years
4-5 Years
5+ Years

6. Where did you receive your training?

7. Check all services that you or your facility provide.
Screening
Clinical Assessment
Rehabilitation/Training
On-Road Assessment
Vehicle Assessment (modifications/equipment needed)
Other   

8. Do you or your facility contract with another agency to provide such services?
Yes  No

If yes, please list the agency(s) and the service(s) provided.

9. What type of driving equipment does your program have?

10. What type of evaluation tools does your program use?

11. How much can the patient expect to pay for driving assessment and/or rehabilitation?

12. Who will receive a report of the assessment outcome?

13. Are you required to notify the Department of Motor Vehicles?
Yes  No

14. Do you or your facility provide any counseling or aid in identifying alternative forms of transportation if the patient can no longer drive?
Yes  No

15. How many patients do you or your facility treat annually?

16. How are patients referred? (Please check all that apply)

Physician
Worker's Compensation
Vocational Rehabilitation
Family
Other

17. What are the reasons for referral? If disability, please list type of disability.

18. What is the most common reason for referral?

19. What is the age of the majority of your patients?

18-25
26-35
36-45
46-55
56-65
66+

20. Are you a member of the Association for Driver Rehabilitation Specialists?
Yes  No

Your Name:

Work Address:

Work Phone No.:

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