Skill Performance Evaluation Certificate Application Form Page 15
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256.
Please give a clinical description of the prosthetic or orthotic device, power source, etc.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
7. Does this driver have any other medical conditions, other than the physical disability indicated in Part III that will
interfere with his/her ability to adequately perform the tasks required?
± No
± Yes - Explain:
_________________________________________________________
_________________________________________________________
8. Please summarize your findings and evaluation, include assessment and medical opinion of whether the condition
will likely remain medically stable over the lifetime of the driver applicant:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Doctor's
Name_______________________________________________Date_____________________
(Print or Type)
Address:
____________________________________________________________
Telephone No.: _____________________________________________
Physiatrist___________ Orthopedic Surgeon____________ Other____________________
Board Certified ___Yes ___ No
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