Evaluation Form

Please complete this evaluation by circling your response and writing comments in the spaces provided.

Overall Impression

1. This guide is a useful and effective physician education tool.

  1. Strongly agree
  2. Agree
  3. Undecided
  4. Disagree
  5. Strongly disagree

2. This guide has raised my awareness of older driver safety as a public health issue.

  1. Strongly agree
  2. Agree
  3. Undecided
  4. Disagree
  5. Strongly disagree

3. I have a better understanding of the medical conditions and medications that may impair my patients’ ability to drive safely.

  1. Strongly agree
  2. Agree
  3. Undecided
  4. Disagree
  5. Strongly disagree

4. I will probably use at least one of the guide’s tools in my clinical practice.

  1. Strongly agree
  2. Agree
  3. Undecided
  4. Disagree
  5. Strongly disagree

5. I have a better understanding of driver rehabilitation options and alternatives to driving.

  1. Strongly agree
  2. Agree
  3. Undecided
  4. Disagree
  5. Strongly disagree

6. I have a better understanding of my state’s reporting requirements regarding patients who may not be safe to operate a motor vehicle.

  1. Strongly agree
  2. Agree
  3. Undecided
  4. Disagree
  5. Strongly disagree


Please rank the usefulness of the following guide materials by circling a number on a scale of 1 to 5.

7. Physician’s Plan for Older Drivers’ Safety (PPODS) Very useful 1 2 3 4 5 Not useful at all
8. Red Flags for Medically Impaired Driving Very useful 1 2 3 4 5 Not useful at all
9. Assessment of Driving-Related Skills (ADReS) Very useful 1 2 3 4 5 Not useful at all
10. State Licensing Requirements and Reporting Laws (Chapter 8) Very useful 1 2 3 4 5 Not useful at all
11. Medical Conditions and Medications That May Impair Driving (Chapter 9) Very useful 1 2 3 4 5 Not useful at all
12. Patient education materials (Appendix) Very useful 1 2 3 4 5 Not useful at all

If you have any additional comments, please write them in the space below.






Please print the requested information.

Name and Title
Address
City
State
Zip
Phone
Fax
E-mail
Medical specialty

Please fax/mail the completed form to:
Catherine Kosinski
American Medical Association
515 N. State Street
Chicago, IL 60610
312 464-5842 fax


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