07782 198 816

Please complete this form either within 1 hour of your driving lesson or with me before entering the car.


* indicates required fields











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

Please give at least 30 minutes notice (travel time for your lesson) and You WILL NOT BE CHARGED if the cancellation is due to Covid-19. You will not be able to resume driving lessons for at least a further 14 days. If the driving lesson is cancelled at your house or during the lesson you will be charged in full.


HEALTH




YES NO


YES NO


YES NO



PERSONAL PROTECTIVE EQUIPMENT (PPE)



NB 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

You must provide your own face covering. Please note this could cause glasses to mist up. You can wear a mask, but this is not compulsory for driving lesson´s. It is currently compulsory for a driving test.

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

You must provide your own gloves. (these should be put on just before you enter the vehicle and I must see you put them on)

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

You will be required to wash your hands thoroughly for at least 20-seconds before leaving the house and entering the car and you should wash your hands after your lesson. You will need to sanitise your hands again when entering the vehicle (you will have to use your own supply. We can not share the same bottle)

I Confirm I Have Just Washed My Hands

I am aware i will be charged the full rate, but may not receive a full 1 hours driving time.

YES NO

All items, such as mobile phones and house keys will have to stay on you and not left on the dashboard or put into door pockets. Any bags you bring, for onward journey must go in the boot









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


v 2.0
NHS & Care Workers Special Offer. Thank you for your selfless dedication and care
If you work full time within the NHS or Care home Sector every driving lesson you take Monday to Friday between 9am & 5pm will cost Just £27 per hour.


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