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The purpose of this Assessment form

The purpose of this Assessment form is to ensure that both yourself as a candidate, and myself as your Driving Instructor, are fully informed of any health conditions or concerns you have regarding personal safety during driving lessons.

It is also to ensure any questions you have are answered and necessary planning and equipment are put in place before we commence all Driving Lessons.

If applicable, please take the time to discuss this form with your family members or those in your household before completing this form to ensure everyone in your home understands the questions and that your answers are accurate.

PLEASE NOTE:

YOU MUST NOTIFY ME IMMEDIATELY IF YOU OR ANY MEMBER OF YOUR IMMEDIATE HOUSEHOLD, SOCIAL CIRCLE OR WORK GROUP DEVELOP COVID-19 SYMPTOMS AND NEED TO SELF ISOLATE.

Visit here for advice on Covid 19 symptoms

You MUST NOT attend any driving lessons or tests if you have any Covid-19 symptoms

You WILL NOT BE CHARGED a short cancellation fee if the cancellation is due to Covid-19


HEALTH




YES NO


YES NO


YES NO



PERSONAL PROTECTIVE EQUIPMENT (PPE)



NB If ‘YES’, you must bring your own products to clean your hands and keep you safe before touching the vehicle or controls in the car.

YES NO

This means my voice may not be as clear or loud. Do you have any difficulties with hearing?

If ‘YES’, please advise details so we can discuss options to work round this issue.

YES NO


YES NO


YES NO

If ‘YES’, I will need to discuss a plan with you prior to lessons to work around this issue

YES NO


YES NO


YES NO

CAR CLEANLINESS

I will be Sanitising the car between every lesson and before and after driving tests with anti-virus grade sanitiser. This means I will be wiping down all touchable surfaces with this sanitiser in spray and/or wipes form. Surfaces include, door frames, door handles inside and out, controls (signals, gear stick, parking brake, bonnet release), mirrors, seatbelts, seat adjusters and seats.



YES NO







Note : Personal information you submit on this form is not shared
or permenantly stored.


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Beth passed 4th of September 2104. Well done!
Beth Campbell

Gemma passed 28th of November 2017, well done!
Gemma Rees


Collingwood Learner Driver Insurance


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