Skill Performance Evaluation Certificate Application Form Page 14
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254. This driver has an impairment of:
' ' ' ' hand or ' ' ' ' upper limb
' ' ' ' hand ( ' ' ' ' partial ' ' ' ' full) or ' ' ' ' upper limb:
has an amputation of:
Does he/she have POWER GRIP and PREHENSION FUNCTION of the hand and fingers?
[Power Grip and precision prehension further defined: the capability of holding, clutching, clasping, or seizing
firmly the steering wheel and/or other vehicle equipment to effectively control the vehicle and perform normal and
emergency vehicle operations [steering (potholes, tire failure (blowouts), etc), operate gear shift levers, air brake
controls, light switches, directional signals, horns].
Right
± Yes
± No
± Yes
± No
Left
If no, do you recommend a surgical reconstruction to produce power grip and/or prehension?
± Yes
± No
5. If this driver has an ' UPPER or ' ' ' ' LOWER LIMB
IMPAIRMENT ( ' Right ' Left)
or has an ' UPPER or ' LOWER LIMB AMPUTATION ( ' Right ' Left)
does he/she have:
a. The APPROPRIATE TYPE OF PROSTHESIS OR ORTHOTIC DEVICE ?
± Yes
± No
b. The appropriate type of TERMINAL DEVICE?
± Yes
± No
c. If yes, does the prosthesis\orthotic fit satisfactorily, is it in good operating
condition?
± Yes
± No
d. Is the applicant able to use the prosthetic/orthotic device proficiently?
± Yes
± No
e. In case of a hand or upper limb amputation or impairment does the
prosthetic/orthotic device aid the driver in the ability to demonstrate
power grasp and precision prehension?
± Yes
± No
If no to any of above, what is your recommendation?
_____________________________________________________________________________________________
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