Program Database Questionnaire

TO ADD NEW PROGRAMS or UPDATE YOUR LISTING:

If your information in the database is current, you do not need to submit this form. To recheck your listing, go to the searchable database located here.

To download and submit a form by mail Click Here (PDF File)

Contact Information:

Program or Business Name:*
Address Line 1:*
Address Line 2:
Address Line 3:
City:*
State:*
Zip Code:*
Web site:
Name and Credentials:*
Phone Number:* (Ex. xxx-xxx-xxxx)	Ext.
Fax Number:
E-mail:*

Does your driving program offer the following service(s):

	YES	NO
Clinical evaluation*
In-vehicle evaluation*
Clinical training*
In-vehicle training*

Does your driving program offer services for drivers of:

	YES	NO
Cars*
Vans*

Do you use a driving simulator for evaluation and training?*

Yes No

Are occupational therapy practitioners on the staff of your driving program?*

Yes No

Do you provide information on alternative information services and programs?*

Yes No

Our driving program provides services to:

	YES	NO
New drivers*
Drivers age 65 and older*

* Indicates required field.