Fitness-to-Drive Screening Measure Online
Contents
1. Page 6 of 10 Use a paper map while driving choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Make a left hand turn crossing multiple lanes and entering traffic with no lights or stop signs choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Parallel park choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O Stay within the lane markings unless making a lane change choose one O Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Stay within proper lane in the absence of road features such as clearly marked lane lines reflectors or rumble strips choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O Keep distance between his or her car and others allow time to react to hazards choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 30 31 32 33 34 35 Page 7 of 10 Look left and right before crossing an intersection choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive in a construction zone choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O Drive in dense traffic such as rush hour choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult2. Pass overtake a car in the absence of a passing lane choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Pass overtake a larger vehicle such as a RV tractor trailer transport truck or dump truck in the absence of a passing lane choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive in an unfamiliar urban area choose one Very Difficult Somewhat Difficult A Little Difficult Not Difficult OoO00 0 36 37 38 39 40 44 Page 8 of 10 Control his or her car when going down a steep hill choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Exit an expressway or inter state from a left hand lane choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive in a highly complex situation such as a large city with high speed traffic multiple highway interchanges and several signs choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Control the car brake hard or swerve to avoid collisions choose one Very Difficult Somewhat Difficult A Little Difficult Not Difficult O OOO Drive a different car such as another person s car or a rental car choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Alter his or her driving in response to changes in health such
3. FTDS Version III 3 25 2013 Fitness to Drive Screening Measure Online A 1 Demographics of Rater Instructions Please answer all questions to the best of your ability In this section we are asking questions about you the family member friend or caregiver who is rating the driver Answer by checking the box or filling in the blank Do not use the back button of the browser it will not return you to the previous set of questions 1 What is your birth year 2 What is your gender Male Female 3 What is your ethnicity Do you consider yourself to be choose one Note We are using these classifications as defined by the National Institutes of Health NIH Hispanic or Latino A person of Cuban Mexican Puerto Rican South or Central American or other Spanish culture or origin regardless of race Not Hispanic or Latino 4 What is your race Would you say you are choose one Note We are using these classifications as defined by the National Institutes of Health NIH American Indian Alaska Native First Nations Aboriginal or Inuit having origins in any of the original peoples of North Central or South America and who maintains tribal affiliation or community attachment Asian having origins in any of the original peoples of the Far East Southeast Asia or the Indian subcontinent including for example Cambodia China India Japan Korea Malaysia Pakistan the Philippine Islands Thailand
4. 2011 Canadian Journal of Occupational Therapy 78 2 72 79 DOI 10 2182 cjot 2011 78 2 2 http cjo sagepub com content 78 2 72 abstract Classen S Winter S M Velozo C B dard M Lanford D N amp Brumback B Lutz B Item Development and Validity Testing for a Safe Driving Behavior Measure 2010 American Journal of Occupational Therapy 64 2 296 305 DOI 10 5014 ajot 64 2 296 http www ncbi nlm nih gov pmc articles PMC2921635 pdf nihms 215506 pdf Fitness to Drive Screening Measure Additional links Fitness to Drive Screening Measure http ftds phhp ufl edu AOTA hitp www aota org Driving Professionals Get Started Screening Self Assessment FTDS aspx Fitness to Drive Video and Press Release UF amp Shands News https m ufandshands org news 2013 uf develops online screening tool help caregivers identify risk older drivers
5. NIH American Indian Alaska Native First Nations Aboriginal or Inuit having origins in any of the original peoples of North Central or South America and who maintains tribal affiliation or community attachment Asian having origins in any of the original peoples of the Far East Southeast Asia or the Indian subcontinent including for example Cambodia China India Japan Korea Malaysia Pakistan the Philippine Islands Thailand and Vietnam Black or African American having origins in any of the black racial groups of Africa Native Hawaiian or Other Pacific Islander having origins in any of the original peoples of Hawaii Guam Samoa or other Pacific Islands White having origins in any of the original peoples of Europe the Middle East or North Africa Other please specify 5 Does the driver live alone If Yes Go to question 8 choose one No Yes Mosily for part of the year 6 Who lives with the driver Spouse or partner Child Family Other relative Friend s Paid caregiver Other please specify 7 Besides the driver you are rating how many other licensed drivers are in his her household 8 What is the driver s highest level of education choose one Did not go to school Completed Grade school 5th grade Completed Middle school 8th grade Completed High School G E D 12th grade Completed Vocational Training Some College after High School Graduation Associate Degree Bachelor s Degre
6. and Vietnam Black or African American having origins in any of the black racial groups of Africa Native Hawaiian or Other Pacific Islander having origins in any of the Original peoples of Hawaii Guam Samoa or other Pacific Islands White having origins in any of the original peoples of Europe the Middle East or North Africa Other please specify 5 What is your highest level of education Did not go to school Completed Grade school 5th grade Completed Middle school 8th grade Completed High School G E D 12th grade Completed Vocational Training Some College after High School Graduation Associate Degree Bachelor s Degree Some Professional School after College Graduation Master s Degree Doctoral Degree 6 Do you have a driver s license choose one No Yes 7 How many days a week do you typically drive choose one Less than 1 NOOR WD 8 Do you live alone If Yes Go to question 10 choose one No Yes Mostly for part of the year 9 Who lives with you Spouse or partner Child Family Other relative Friend s Paid caregiver Other please specify 10 What is your relationship with the driver you are rating choose one Spouse or partner Child Family Other relative Friend s Paid caregiver Other please specify 11 Besides you how many other licensed drivers are in your household 12 Do you rely on the driver for any of the following trips or activities Choose all th
7. motorcyclists 10 Drive on a highway with two or more lanes in each direction 1 Stay in the proper lane 12 Keep distance from other vehicles when changing lanes 14 Drive cautiously to avoid collisions in situations when others are driving erratically such as speeding road rage crossing lane lines or driving distracted 3 Use the car controls such as the turn signals emergency brake windshield wipers or headlights 27 Stay within the lane markings unless making a lane change 18 Enter the flow of traffic when turning right 20 Drive on graded unpaved road 6 Obey varied forms of traffic lights such as green arrow for turn lane or flashing lights 30 Look left and right before crossing an intersection 4 19 2013 4 18 13 Fitness to Drive Screening Measure Recommendations Fitness to Drive Screening Measure Online Keyform Results Recommendations EA i At Risk Driver Overall rating Based on your rating the driver is classified within the At Risk Driver Group which means that although the driver can perform some basic driving skills there are safety concerns that need immediate attention The driving skills causing concern are 1 Drive in an unfamiliar area 2 Drive when upset anxious worried sad or angry 3 Drive in dense traffic such as rush hour Specific Recommendations We recommend the driver see a doctor for a physical exam as soon as possible and not drive un
8. Fitness to Drive Screening Measure Keyform Results 1 2 le Page 3 of 5 33 Pass overtake a car in the absence of a passing lane 37 Exit an expressway or inter state from a left hand lane 32 Drive in dense traffic such as rush hour 7 Drive and hold a conversation with one or more passengers 39 Control the car brake hard or swerve to avoid collisions 8 Drive with a passenger who is providing driving directions or assistance 22 Drive with surrounding tractor trailers transport trucks 21 Check blind spots before changing lanes 52 Control his or her car on a wet road 5 Read road signs far enough in advance to react such as make a turn 2 1 2 3 2 3 2 3 http ftds phhp ufl edu keyform php 17 Back out of parking spots 4 19 2013 Fitness to Drive Screening Measure Keyform Results 2 2 3 4 2 o 4 2 3 Q 2 3 2 3 2 4 2 Q 2 2 amp sa 1 2 Q 2 Q 2 le 1 2 3 Q 2 3 4 http ftds phhp ufl edu keyform php Page 4 of 5 11 Keep up with the flow of traffic 36 Control his or her car when going down a steep hill 2 Check for a clear path when backing out from a driveway or parking space 15 Brake at a stop sign so car stops completely before the marked line 4 Check car mirrors when changing lanes 19 Share the road with vulnerable road users such as bicyclists scooter drivers
9. as vision reaction time fatigue thinking joint stiffness medications choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 42 43 44 45 46 47 Page 9 of 10 Drive when upset anxious worried sad or angry choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Stay focused on driving when there are distractions such as radio eating drinking pet in the car choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive in an unfamiliar area choose one Very Difficult Somewhat Difficult A Little Difficult Not Difficult O00 0 Drive at night choose one Very Difficult Somewhat Difficult A Little Difficult Not Difficult O OOO Avoid dangerous situations such as car door opening car pulling out road debris or an animal darting in front of car choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive when there is fog choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 48 49 50 51 52 53 54 Page 10 of 10 Drive at night on a dark road with faded or absent lane lines choose one O O O O O O O Very Difficult Somewhat Difficult A Little Difficult Not Difficult Very Difficult Somewhat Difficult A Little Difficult Not Difficult Drive when there is
10. at apply Shopping Grocery store Social activities See friends or family Church See doctor or get medical care Work related activities Do not rely Other please specify 13 How many days a week do you ride with the driver you are rating choose one Less than 1 NOOR WDD 14 If the driver you are rating reduced or stopped driving would it significantly impact your current lifestyle No Yes 15 If Yes to question 14 please explain FTDS Version III 3 25 2013 Fitness to Drive Screening Measure Online A 2 Demographics of Driver Instructions Please answer all questions to the best of your ability In this section we are asking questions about the driver you are rating Answer by checking the box or filling in the blank Do not use the back button of the browser it will not return you to the previous set of questions 1 What is the driver s birth year 2 What is the driver s gender Male Female 3 What is the driver s ethnicity Do you consider the driver to be choose one Note We are using these classifications as defined by the National Institutes of Health NIH Hispanic or Latino A person of Cuban Mexican Puerto Rican South or Central American or other Spanish culture or origin regardless of race Not Hispanic or Latino 4 What is the driver s race choose one Note We are using these classifications as defined by the National Institutes of Health
11. e Some Professional School after College Graduation Master s Degree Doctoral Degree 9 Does the driver use any of the following assistive devices Choose all that apply Corrective lenses such as eyeglasses or contacts Hearing device hearing aid Mobility device Such as cane walker wheelchair Car devices such as seat pad pedal assist spinner knob Other please specify FTDS Version III Fitness to Drive Screening Measure Online 3 25 2013 B Driving History Profile of Driver Instructions 1 Please answer all 31 questions to the best of your ability 2 Answer by checking the box or filling in the blank 3 Do not use the back button of the browser it will not return you to the previous set of questions 1 How many days a week does the driver typically drive Less than 1 1 N O17 B W PO 2 Who usually rides with the driver Check all that apply Spouse Partner Family Other relative Friend s Paid caregiver No one Other please specify 3 Has a health condition limited the driver s ability to drive choose one No Yes 4 Has taking medications limited the driver s ability to drive over the counter or prescribed choose one No Yes 5 Did the driver get any of the following tested in the last year Check all that apply Vision Hearing Physical exam checkup Other tests list 6 In the past year did the driver complete or have done any of the followi
12. glare or the sun is in his or her eyes choose one Turn left across multiple lanes when there is no traffic light choose one O O O O Drive in a thunderstorm with heavy rains and wind choose one O O O O Control his or her car on a wet road choose one O O O O Drive on a snow covered road choose one O O O O Drive on an icy road choose one O O O O Very Difficult Somewhat Difficult A Little Difficult Not Difficult Very Difficult Somewhat Difficult A Little Difficult Not Difficult Very Difficult Somewhat Difficult A Little Difficult Not Difficult Very Difficult Somewhat Difficult A Little Difficult Not Difficult Very Difficult Somewhat Difficult A Little Difficult Not Difficult Fitness to Drive Screening Measure Keyform Results Page 1 of 5 Fitness to Drive Screening Measure Online Recommendations Keyform Results Select parameters then click Update to build Keyform output Items caregiver_20120522 n200 Sessions 1870 00 08 55 2013 04 16 18 41 01 Clustering hard to easy rounded average 5 Show Responses All Total Items 50 Outfit mean squared 0 72 Outfit Z score 1 54 Infit mean squared 0 67 Infit Z score 1 88 Person Measure 52 88 out of 100 0 65 logits Rating Scale Item Description 0 10 20 30 40 50 60 70 80 90 100 1 1 1 1 1 1 1 1 1 2 3 4 54 Drive on an icy road htt
13. ng car maintenance choose all that apply Oil change Checking tires Checking fluid levels Checking headlights brake lights and parking lights 7 Does the driver avoid when possible any of these driving situations choose all that apply Rush hour heavy traffic Interstate highway driving Rain Night time driving Left hand turns against traffic None Other please specify 8 Has the driver been involved in a crash in the past 3 years If you mark No go to question 10 choose one No Yes 9 How many crashes was the driver involved in during the past 3 years as a driver not passenger 1 2 3 4 5 or more 10 How many moving violations citations or traffic tickets has the driver had in the past 3 years If you mark 0 go to question 12 choose one 1 2 3 4 5 or more 11 What moving violations citations or traffic tickets did the driver receive in the past three years Check all that apply Failure to yield Going too slowly Not obeying traffic lights Not obeying traffic signs such as stop sign Improper passing Improper turning Careless driving Reckless driving Driving under influence of drugs or alcohol DUI DWI Speeding Tailgating Do not know Other please specify 12 When did the driver last attend a driver education training or retraining course If you mark Never go to question 14 choose one Within the past year 1 3 years ago More than 3 years ag
14. o Never Do not know 13 If they attended a driver education class training or re training what type was it choose all that apply On line class Classroom course for all drivers Classroom course for mature drivers Course with classroom and behind the wheel instruction Do not know Other please specify 14 How does the driver keep up with changes in road rules or laws choose all that apply Driving class Newspaper Driver s handbook Friends or family Computer Police or law enforcement Driver s license office DMV None of the above 15 16 17 18 19 20 21 22 23 24 Do not know Other please specify Does the driver have difficulty opening the car door choose one No Yes Does the driver have difficulty getting into his or her car choose one No Yes Is it difficult for the driver to adjust the car mirrors appropriately choose one No Yes Does the driver have difficulty adjusting the driver s seat so he or she can see above the steering wheel choose one No Yes Is the driver able to reach the gas pedal accelerator and brake pedal choose one No Yes Does the driver remember to turn on the headlights before driving in the dark choose one No Yes Does the driver use their seatbelt choose one Always Often Sometimes Rarely Never Can the driver press the gas pedal or the brake pedal when intended choose one No Yes Is it difficult for the d
15. o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Brake at a stop sign so car stops completely before the marked line choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O Maintain lane when turning not cut corner or go wide choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Back out of parking spots choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 18 19 20 21 22 23 Page 5 of 10 Enter the flow of traffic when turning right choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Share the road with vulnerable road users such as bicyclists scooter drivers motorcyclists choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive on graded unpaved road choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O Check blind spots before changing lanes choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Drive with surrounding tractor trailers transport trucks choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Merge onto a highway choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 24 25 26 27 28 29
16. omewhat Difficult doing it is a moderate challenge A Little Difficult doing it is a minor challenge Not Difficult can do it with ease For each question please select your answer by clicking on the text or circle Do not use the back button of the browser it will not return you to the previous set of questions Note the example below FOR THE PERSON YOU ARE RATING BASED ON THE LAST 3 MONTHS HOW DIFFICULT IS IT FOR HIM OR HER TO A Start the car Very Difficult Somewhat Difficult A Little Difficult Not Difficult O O O O Page 2 of 10 FOR THE PERSON YOU ARE RATING BASED ON THE LAST 3 MONTHS HOW DIFFICULT IS IT FOR HIM OR HER TO 1 Stay in the proper lane choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 2 Check for a clear path when backing out from a driveway or parking space choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 3 Use the car controls such as the turn signals windshield wipers emergency brake or headlights choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O 4 Check car mirrors when changing lanes choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O 5 Read road signs far enough in advance to react such as make a turn choose one o Very Difficult o Somewhat Difficult o A Little Diffic
17. p ftds phhp ufl edu keyform php 4 19 2013 Fitness to Drive Screening Measure Keyform Results Page 2 of 5 1 2 3 4 24 Use a paper map while driving 1 2 3 4 51 Drive in a thunderstorm with heavy rains and wind fl 2 3 4 49 Drive when there is glare or the sun is in his or her eyes 1 3 4 53 Drive on a snow covered road Bl 3 4 35 Drive in an unfamiliar urban area i l 3 4 44 Drive in an unfamiliar area i 3 4 45 Drive at night g 2 3 4 47 Drive when there is fog ale 2 3 4 34 Pass overtake a larger vehicle such as a RV tractor trailer transport truck or dump truck in the absence of a passing lane i 3 4 42 Drive when upset anxious worried sad or angry 2 4 50 Turn left across multiple lanes when there is no traffic light 2 gt 4 43 Stay focused on driving when there are distractions such as radio eating drinking pet in the car 2 4 41 Alter his or her driving in response to changes in health such as vision reaction time fatigue thinking joint stiffness medications 40 Drive a different car such as another person s car or a rental car N A 2 amp 4 25 Make a left hand turn crossing multiple lanes and entering traffic with no lights or stop signs 2 3 4 46 Avoid dangerous situations such as car door opening car pulling out road debris or an animal darting in front of car http ftds phhp ufl edu keyform php 4 19 2013
18. river to drive during daylight hours choose one No Yes Does the driver place the car in the correct gear such as drive or reverse choose one No Yes 25 Does the driver have any difficulty turning the steering wheel choose one No Yes 26 Does the driver stop for pedestrians crossing the street choose one No Yes 27 Is it difficult for the driver to drive in good weather choose one No Yes 28 As the driver on a long trip how frequently would the driver take breaks choose one Every 1 to 2 hours Every 3 to 4 hours Every 5 to 6 hours Rarely or Never 29 Does the driver have trouble staying awake while driving choose one No Yes 30 Does the driver use alternative transportation Such as taking a bus or taxi choose one Always Often Sometimes Rarely Never 31 Do you think the driver would consider alternative transportation if it were available choose one No Yes Page 1 of 10 FTDS Version III Fitness to Drive Screening Measure Online 2 25 2013 C Fitness to Drive Screening Measure Instructions 1 Please answer all 54 questions to the best of your ability 2 From your observations of the driver over the past three months rate the amount of difficulty for each skill If you have not observed the driver for a skill use your best judgment to rate the difficulty the driver would have using one of the following answers Very Difficult doing it is a major challenge S
19. stitute for Mobility Activity and Participation I MAP 2013 University of Florida This page uses Google Analytics Google Privacy Policy ftds phhp ufl edu results php 2 2 Publications for Fitness to Drive Screening Measure formerly known as the Safe Driving Behavior Measure 1 Classen S Wang Y Velozo C B dard M Winter S M amp Lanford D N 2013 Concurrent Criterion Validity of the Safe Driving Behavior Measure A Predictor of On Road Driving Outcomes American Journal of Occupational Therapy 67 1 108 116 DOI 10 5014 ajot 2013 005116 http ajot aotapress net content 67 1 108 full pdf html Classen S Wen P Velozo C B dard M Winter S M Brumback B Lanford D N 2012 Psychometrics of the Self Reported Safe Driving Behavior Measure for Older Adults American Journal of Occupational Therapy 66 2 233 241 DOI 10 5014 ajot 2012 001834 http ajot aotapress net content 66 2 233 full pdf html Classen S Wen P Velozo C B dard M Brumback B Winter S M amp Lanford D N 2012 Rater Reliability and Rater Effects of the Safe Driving Behavior Measure 2011 American Journal of Occupational Therapy 16 69 77 DOI 10 5014 ajot 2012 002261 http ajot aotapress net content 66 1 69 full pdf html Winter S M Classen S B dard M Lutz B Velozo C A Lanford D N amp Brumback B Focus Group Findings for a Self report Safe Driving Behavior Measure
20. til he she is able to undergo a comprehensive driving evaluation conducted by a Certified Driving Rehabilitation Specialist Information on the use and access to alternative transportation other than the personal automobile may be available from the local Area Agency on Aging or contact the Eldercare Locator at 800 677 1116 General Recommendations Based on guidelines of The American Geriatrics Society we recommend an eye exam annually or earlier if there are changes in health or vision For further details on driving or community mobility click on the links below Resources AAA Resources for Mature Drivers e American Automobile Association AAA ftds phhp ufl edu results php 1 2 4 18 13 Fitness to Drive Screening Measure Recommendations http seniordriving aaa com AARP Driver Safety e AARP http www aarp org drive Certified Driving Rehabilitation Specialists Occupational Therapists providing the Comprehensive Driving Evaluations e American Occupational Therapy Association http www aota org Older Driver Specialists aspx Information and free resources to help you become more familiar with transportation resources and services available in your community e National Center on Senior Transportation http seniortransportation easterseals com site PageServer pagename NCST2_older UNIVERSITY of FLORIDA The Foundation for The Gator Nation Home Disclaimer Privacy Policy User Manual Contact Us UF In
21. ult o Not Difficult Page 3 of 10 6 Obey varied forms of traffic lights such as green arrow for turn lane or flashing lights choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O 7 Drive and hold a conversation with one or more passengers choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 8 Drive with a passenger who is providing driving directions or assistance choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 9 Drive in light rain choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 10 Drive on a highway with two or more lanes in each direction choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 11 Keep up with the flow of traffic choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult 12 13 14 15 16 17 Page 4 of 10 Keep distance from other vehicles when changing lanes choose one o Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult Change lanes in moderate traffic choose one Very Difficult o Somewhat Difficult o A Little Difficult o Not Difficult O Drive cautiously to avoid collisions in situations when others are driving erratically such as speeding road rage crossing lane lines or driving distracted choose one
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