Skill Performance Evaluation Certificate Application Form Page 13
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25PART III
THIS PART TO BE COMPLETED BY ORTHOPEDIC SURGEON OR PHYSIATRIST
Based upon this job task description (as indicated in Part II-A, B, and C) and your examination of this driver, please
answer all questions below.
It is not necessary for physician to state whether this person is likely to be a safety risk on the highway. Our SPE
Specialist will conduct skill performance evaluations in the intended vehicles to determine whether limb-handicapped
persons have overcome their handicaps. We are relying on your medical measurements and judgement for such
information as asked below:
1. Does this driver have adequate MUSCLE STRENGTH to perform the tasks required:
± Yes
± No If no, please indicate the impaired extremity.
± Right
± Left
Upper Extremity
Lower Extremity
± Right
± Left
2. Does this driver have adequate MOBILITY of the extremities and trunk to perform the tasks required?
± Yes
± No If no, please indicate the impaired extremity.
± Right
± Left
Upper Extremity
Lower Extremity
± Right
± Left
±
Trunk
3. Does this driver have adequate JOINTS and TRUNK STABILITY to perform the tasks required?
± Yes
± No If no, please indicate the impaired extremity.
± Right
± Left
Upper Extremity
± Right
± Left
Lower Extremity
±
Trunk
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