D1325 Scooter/EWC Assessment Form (PDF 180 KB)

NameFile No.NOTE: The veteran’s eligibility for a scooter must be established by DVA as a reduction in functional mobility resultingfrom an Accepted Disability (AD), before proceeding with this assessment.1: Relevant medical historyThese items require DVA Prior ApprovalRefer DVA RAP National Guidelines for Electric Mobility Aids, www.dva.gov.au2: HeightCm3: WeightKg4: MobilityActual distance the entitled person can walkmetres5: Is mobility likely to improvewith time or alternative aid (e.g.post THR)?6: Please describe mobility indoorsAND outdoors (include mobilityaids used).NoEquipmentYes7: Please describe upperlimb AND lower limb function(dexterity, strength, co-ordination,range of movement, balance).8: Please describe vision9: Hearing:NormalImpairedHearing aid?NoYes Left ear Right ear BothD1325 09/11 P.2/10

NameFile No.10: Cognitive ability (considermemory, orientation, perceptualskills, response time).Comment on standardised cognitive assessments if appropriate11: Social situation/Domicile:(Please tick appropriate box)Lives aloneHome/UnitSpouse Other family FriendRetirement village Nursing homeHostelHome ownership:OwnerRentsOtherCommentsSpouse/carer/family/community services able to assist with use of mobility aid/community access?NoYesPlease provide details12: Beneficiary’s ADL:Independent Assistance Dependent Equipment usedBathingToiletingTransfersShoppingFinancemanagementMail collectionComments (inc. shopping, housework, laundry, taking out garbage etc.)D1325 09/11 P.3/10

NameFile No.13: Reasons for assessment(Refer to Scooter and EWCGuidelines)Functional Criteria1.Severereduction inmobility2. 3.Cannot usewheelchairCarer unableto pushwheelchairSocial CriteriaReducesocialisolationWill reducedependenceon carerReduce needfor institutional/community careOther14: What transport does theveteran currently use to accessthe community (commenton frequency of outings anddestinations)?Does the veteran drive?NoYesDoes the veteran have a restricted license?NoYesIs there a history of driving accidents?NoYesDoes the carer drive?NoYesDoes/could the veteran have a taxi voucher?NoYesDoes the veteran receive Recreational Transport Allowance?NoYesNOTE: DVA will not fund hoists, ramps or trailers required for transportation forthe motorised aids.Comments15: Veteran’s requirements for theScooter/EWC:Home: Internal ExternalFor what functional purpose will the vehicle be used?Intended usage of scooter (comment on proposed destinations and frequencyContinued next page...D1325 09/11 P.4/10

NameFile No.Community access:Immediate neighbourhoodShopping centreOtherDistance to be travelled per dayTerrain (please tick)Steep > 1:8UnevenFootpathSealed pathSloped 1:8EvenRoadUnsealed pathGrassLevelWill access ramps be required?No YesNOTE: DVA will not fund ramps for scooter access.Comments16: Storage and maintenance:NB: it is the responsibility ofthe veteran to provide a securestorage site.Storage siteNOTE: An extension lead of 3 metres can be used, but it must remain in thesame building (AS 3000).Is the area lockable and waterproof?No YesDoes the veteran/carer understand:Recharging requirements? NoYesGeneral maintenance?Protocol for repairs?Will the veteran be providedwith a vehicle handbookand local supplies details?NoNoNoYesYesYesContinued next page...D1325 09/11 P.5/10

NameFile No.CommentsOT Prescriber signatureDate/ /Proceed to trial ONLY AFTER being contacted by RAP/OT AdvisersD1325 09/11 P.6/10

NameFile No.3: Was the veteran safely able to:continued..Negotiate:Narrow paths ordoorwaysNo Yes Sometimes CommentsCross roadsRough groundOther vehiclesSlopes/curbed rampsPedestriansObserve road rulesAbility to turn head toscan for hazardsTrunk/head supportsrequired?A bilateral mirror is requiredFurther commentsD1325 09/11 P.8/10

NameFile No.3: Was the veteran safely able to:continued..Judge space anddistanceNo Yes Sometimes CommentsRespond inappropriate timeUse hornappropriatelyRemember to turn on/off machineRemain nondistractedMaintain appropriatebehaviourWas veteran able tosafely transfer on/offvehicle?Comment on attention, concentration, memory, follow directions4: Is further OT trainingrecommended?NoCommentsYesD1325 09/11 P.9/10

NameFile No.5: Vehicles tested(2 - 3 vehicles should be trialledif practicable)NameTrial dateSupplierCostMaximum speedof vehicleMaximum weightof vehicle1/ /$2/ /$3/ /$6: Vehicles choice at completion ofassessment:NameSpecifications (e.g. flag)Helmet details (where applicable)Reasons for choice7: Is the veteran aware oftheir responsibilities to organisecomprehensive insurance forpublic liability and damage tothe vehicle?NoYesNOTE: Personal Injury Insurance is advisable.8: OT Prescriber signatureDate/ /D1325 09/11 P.10/10