Driver Screening and Evaluation Program
Volume II: Maryland Pilot Older Driver Study
NOT FOR MARYLAND MVA USE
First Name, Middle Initial, Last Name
Gender: (1) Male; (2) Female
Date of Birth (YYYY, MM, DD)
Race:(1) African-American; (2) American Indian; (3) Asian; (4) Caucasian; (5) HispaniC; (6) Other
Driver’s License Number:
Employment Status: (1) Unemployed; (2) Working Part Time; (3) Working Full Time; (4) Retired
1.How many days per week do you normally drive?
2.How many total miles do you drive in a normal week?
3.About how many miles per year do you drive?
(Present the driver with the card that lists the response choices. For each statement, circle the number below the chosen frequency estimate.)
4a. Do you avoid driving at night?
4b. Do you avoid making left turns across oncoming traffic?
4c. Do you avoid driving in bad weather (rain, snow, fog, etc.?)
4d. Do you avoid driving on high-traffic roads?
4e. Do you avoid driving in unfamiliar areas?
4f. Do you pass up opportunities to go shopping, visit friends, etc., because of concerns about driving?
5. Have you fallen to the floor or ground in the past 3 years? (NOTE: A trip or stumble doesn’t count)
6. Would you have difficulty walking one block or climbing one flight of stairs?