Vehicle Assessment Form

This form is to be completed by the assessor during the Vehicle Assessment to aid recording of information. ECCH adheres to full GDPR compliance.

Section 1: Relevant Subjective and Background Information

Date *

DD/MM/YYYY

Name *

Job Title and Service/Locality *

Contracted Hours *

Full time Part time

Driver email address *

Location of Assessment *

Informed Consent Gained

Assessment *

Verbal Written N/A

Measurement *

Verbal Written N/A

Photography *

Verbal Written N/A

Report *

Verbal Written N/A

(to named person)

Vehicle Type

Car

Manual Automatic

Transit Van

Manual Automatic

Other (detail later)

Manual Automatic

List Vehicle Make and Model

List any special features such as pedal adaptations

Detail any current or relevant physical health conditions that may impact the driver

Detail any current or relevant mental health conditions that may impact the driver, e.g. anxiety

Detail user reported Issues and difficulties related to vehicle and driving

(Consider MSD’s or other physical difficulties, current management, impact on driving, functional issues aggravating and easing factors, ‘fit’ problems identified by driver)

Job Demands - distance,repetitive in/out of car/open/closing boot

Job Demands - Average hours of work seated in vehicle per month

(include any administrative tasks)

Job Demands - Details of Driving

In traffic jams/congested areas In rural locations Using cruise control Frequent new locations

(tick all that apply)

Job Demands -How likely are you to use a Smart phone in your vehicle for activities other than voice calls?

0 - Not at all likely 1 2 3 4 5 6 7 8 9 10 - Extremely Likely

Job Demands - How likely are you to use a Tablet or Laptop in your vehicle?

0 - Not at all likely 1 2 3 4 5 6 7 8 9 10 - Extremely Likely

Job Demands - How likely are you to use a Satellite Navigation System in your vehicle?

0 - Not at all likely 1 2 3 4 5 6 7 8 9 10 - Extremely Likely

Job Demands - Manual Handling Activities In/Out of Vehicle (On a typical day)?

Very Unlikely/Never