Adult Driving Environment WOS Rater Report Form Ages 21-87 years unlocking potential LiDiane Parham, PhD, OTR/L, FAOTA Cheryl L. Ecker, MA, OTR/L_ TaraJ. Glennon, EdD, OTR/L, FAOTA, Diana A. Henry, MS, OT/L, FAGTA Heather Kuhaneck, PhO, OTR/L, FAOTA, Instructions: Please answer these questions based onthe individuals typical behavior during the past month, Using the following rating scale, select the one answer that best describes haw often the benavior happens. Never: The behavior never or almost never happens. Oceasienally: The behavior happens some ofthe time. Frequently: The behavior happens much ofthe time. ‘Always: The behavior always or almost always happens. When driving, this inividual Never Occasionally Frequently _Alays 1. Has trouble judging the speed of oncoming cars when making let turns 1 2 3 4 2. Falls to notice tratfic signals or signs. 1 2 3 4 3, Is confused by road-sign symbols. 2 3 4 4, Has trouble knowing where to look 1 2 3 4 5: Has rouble jdgingtedtace tween ther another vies oreets suchas | > 3 4 6. Is bothered by the sounds of other cars or trucks passing by. 1 2 3 a 7. Falls to hear sirens until emergency or police vehicles are very close, 1 2 3 4 8, Has trouble determining where the sounds of sirens are coming from. 1 2 3 4 9, Has trouble fining the correct pedal (gas or brake). 1 2 3 4 10. Has trouble making small adjustments to the steering wheel to drive ina straight ine. 1 2 3 4 11, Has trouble knowing how much to turn the steering wheel fora sharp or wide tur, 1 2 3 4 112, Has trouble knowing how hard to press on the gas pedal or brake, 1 2 3 4 13. Confuses right and left turns. 2 3 4 114. Becomes disoriented or confused when turning head to change lanes or back up. 1 2 3 4 15, Gets dizzy when making a tur. 2 3 4 16. Has trouble backing up inthe intended direction, 1 2 3 4 17, Has trouble following directions toa new place without a GPS. 1 2 3 4 118, Has trouble changing lanes or merging smoothly int traffic 1 2 3 4 Driving Rater Report Total Score ‘The SPM-2is available online at platform.wpspublish.com. copyright © 2021 by Western Payeholgiel Services. Quaid users of his content ae pernitted to reproduce this frm for ‘he Sle purpose of ndvicul appliaton. No ether use—incucing and notte te acaptabon and/or translation may be ‘made without the prior permission of WPS (ightsEwpspublsh.com).Allghts reserved. 98765432Adult Driving Environment VAY @}S: Self-Report Form Ages 21-87 years unlocking potential L.Diane Parham, PhD, OTR/L, FAOTA Cheryl L, Ecker, MA, OTR/L_ Tara J, Glennon, EdD, OTR/L, FAOTA, Diana A. Henry, MS, OT/L, FAGTA Heather Kuhaneck, PhO, OTR/L, FAOTA, Name Today'sdate | Dateofbirth | Age | Gender Instructions: Pease answer these questions based on your typical behavior during the past month. Using the following rating le. elect the one answer that best describes how a‘ten the behavior happens "Never: The behavior never or almost never happens. ‘Oceaslonally: The behavior happens some ofthe time. Frequently: The behavior happens much ofthe time ‘Always: The behavior always or almost always happens. When driving. Never _ceainaly Frequently Abaya 1. Ihave trouble judging the speed of oncoming cars when I make left turns 2 3 4 2. Ihave trouble noticing traffic signals orsign. 2 3 4 3. | get confused about the meaning of road-sign symbols, 1 2 3 4 4, Ihave trouble knowing where to look. 1 2 3 4 5: avr judge tance etveenthe cara ther ees eros suchas : > 3 ‘ 6. Lam bothered by the sounds of other ears or trucks passing by. 2 3 4 7. Ifailte hear sirens until emergency or police vehicles are very close 1 2 3 4 8. Ihave trouble determining where the sounds of sirens are coming from. 1 2 3 4 9, Ihave trouble fincing the correct pedal (gas ar brake) with my foot 1 2 3 4 20, | have trouble making small adjustments tothe steering wheel to drive ina straight line 2 3 4 11, Thave trouble knowing how much to turn the steering wheel fora sharp of wide turn, 1 2 3 4 12, | have trouble knowing how hard to press on the gas pedal or brake, 1 2 3 4 13. Ieonfuse right and lett turns. 2 3 4 114. | get cisoriented or confused when I turn my head to change lanes or back up. 2 3 4 15. | get izzy when making a turn 1 2 3 4 16. | have trouble backing up in the direction | intend. 1 2 3 4 17. | have trouble folowing directions to anew place without a GPS, 1 2 3 4 18, | have trouble changing lanes or merging smoothly into traffic 2 3 4 Driving Set Report Total Score ‘The SPM-2is available online at platform.wpspublish.com. copyright © 2021 by Western Payeholgiel Services. Quaid users of his content ae pernitted to reproduce this frm for ‘he Sle purpose of ndvicul appliaton. No ether use—incucing and notte te acaptabon and/or translation may be ‘made without the prior permission of WPS (ightsEwpspublsh.com).Allghts reserved. 98765432Bw Adult Driving Environment Rater Report Form unlocking potential ‘Ages 21-87 years S P M ™ 2 LiDiane Parham, PhD, OTR/L, FAOTA Cheryl L. Ecker, MA, OTR/L_ TaraJ. Glennon, EdD, OTR/L, FAOTA, Diana A. Henry, MS, OT/L, FAGTA Heather Kuhaneck, PhO, OTR/L, FAOTA, ‘Translation by Susana Urbina, PD oF favor conteste estas preguntas en base aa canducta tipiea del indlviduo durante el mes pasado. Seleccione {Que mejor deseriba la frecuencia con la cual esta canducta ocurre, usando la siguiente escala de evaluacisn. ‘Nunea: La conducta nunca 9 eas nunca ocurr. Ocasionalmente: La conducta ocurre a veces Frecuentemente: La conducta ocurre a menudo, ‘Siempre: La conducta ocurre siempre o casi siempre. Cuando manela, este individuo.. Morea Ocasnanerta Reatctonerte Sere 1 Tl ite et lc eu arin Sa a a8 y > 3 ’ 2, No nota las sefiales de trtico o los letreros. 1 2 3 4 3, Se confunde con los simbolos de las seiales en fa carretera, 1 2 3 4 4, Tiene diticultad para saber dénde mirar 1 2 3 4 5 Tapa pebines hupad ndstanok mir slatoy ocr bdevoncteiorecreon | > 3 4 6, Se fastida con los sonidos de otros autos o camlones que estén pasando cerca, 1 2 3 4 7. No oye las sirenas hasta que los vehiculos de emergencia ode la poicia estan muy cerca. | 1 2 3 4 8, Tiene dficultad para distingulr de donde provienen los sonidos de las sirenas. 1 2 3 4 89. Tiene dificultad para encontrar el pedal corecto (para acelerarofrenar) 1 2 3 4 10. Tiene difcultad haciendo pequefos cambios con el timén pare poder manejaren tinea recta, | 1 2 3 4 11. Tiene difcultad para saber cuanto girarelimén para dar una vuelta cerrada amplia 1 2 3 4 12. Tiene difcuttad para saber que tan fuerte presionar el acelerador oelfreno. 1 2 3 4 13, Confunde los gros ala derecha y la izquerd 1 2 3 4 14, Se desorienta o se confunde cuando volta la cabeza para cambiar de carriloretroceder. | 1 2 3 4 15, Se marea alhacer un giro, 1 2 3 4 16. Tiene problemas retrocediendo en a dreccién que desea, 1 2 3 4 117, Tiene problemas en seguirlas indicaciones de cémo legar aun lugar nuevo sun GPS. | 2 2 3 4 18. Tiene difcuttad para cambiar de carlo unis al tréfcoféclimente, 1 2 3 4 Driving Rater Report Total Score ‘The SPM-2is available online at platform.wpspublish.com. copyright © 2021 by Western Payeholgiel Services. Quaid users of his content ae pernitted to reproduce this frm for ‘he Sle purpose of ndvicul appliaton. No ether use—incucing and notte te acaptabon and/or translation may be ‘made without the prior permission of WPS (ightsEwpspublsh.com).Allghts reserved. 98765432Bw Adult Driving Environment Self-Report Form unlocking potential ‘Ages 21-87 years S P M ™ 2 L.Diane Parham, PhD, OTR/L, FAOTA Cheryl L, Ecker, MA, OTR/L_ Tara J, Glennon, EdD, OTR/L, FAOTA, Diana A. Henry, MS, OT/L, FAGTA Heather Kuhaneck, PhO, OTR/L, FAOTA, Translation by Susana Urbina, PRD Nombre Fecha de hoy Fechadenacimiento] Edad | Sexo Instrucciones: Por favor contesta estas preguntas en base a fu conducta tipica durante el mes pasado, Selecciona solo la respuesta {que mejor deseribala frecuencia con Ia cual esta conducta ocurre, usando la siguiente escala de evaluacin. ‘Nunea: La conducta nunca o casi nunes ocurre. Ocasionalmente: La conducta ocurre a veces. Frecuentemente: .a conducta ocurre a menudo. ‘Siempre: La conducta ocurre siempre 0 cas siempre. Cuando manejo ores Ocarrainerie_Fetetenente Serpe 1. Yo tengo difculfad juzgando le velocidad de autos que se aproximan cuando hago gros | 2 3 ’ ala iquierda 2. Yo tengo sificultad en notar las sefiales detrtico olos letreros. 1 2 3 4 2. Yome contundo com los simbolos de las sefales en la carretera 1 2 3 4 4. Yo tengo difieultad para saber dénde mirar 1 2 3 4 5, Yotengo problemas juzgando la distancia entre el auto y otras vehicules uabjetas come un poste de ki oun surticor de gasalina, 2 2 3 4 6, Me molestan los sonidos de otros autos o camiones que estén pasando cerca 1 2 3 4 7. Yow iglesrons ast quelon veholon de regain dapat atin 1 2 > ‘ £8. Yo tengo dficultad para distingulr de donde provienen los sonidos de las sirenas, 1 2 3 4 8. Yo tengo dificultad para encontrar el pedal orrecto (aceleradoro freno) con el pe. 1 2 3 4 20. Yo tengo feud haciendo pues cambios contin para poder mansaren ; > > 4 1, Yo tengo diicultad para saber cusnto gira eltimén para dar una vuelta cerradaeampla, | 2 2 3 4 12. Yo tengo difcultad para saber que tan {uertemente presionar elacelerador ol reno, 1 2 3 4 13. Yo confundo los giros ala derecha y ala izquierda. 1 2 3 4 114, Yo me desoriento o me confunda cuando vokea la cabeza para cambiar de carro retroceder z Z 8 4 15, Yome mareoal hacer un gio, 1 2 3 4 16. Yo tengo problemas retrocediendo en a direccién que deseo. 1 2 3 4 17 Yo tengo problemas en seguir las indicaciones de cma llegar aun lugar nuevo snun GPS. | 2 2 3 4 18. Yo tengo dificultad para cambiar de carlo unirme al rico tcilmente 1 2 3 4 Driving Self Report Total Score ‘The SPM-2is available online at platform.wpspublish.com. copyright © 2021 by Western Payeholgiel Services. Quaid users of his content ae pernitted to reproduce this frm for ‘he Sle purpose of ndvicul appliaton. No ether use—incucing and notte te acaptabon and/or translation may be ‘made without the prior permission of WPS (ightsEwpspublsh.com).Allghts reserved. 98765432