Substance Use Evaluation

Form Template

The Substance Use Evaluation form is a comprehensive app to gather information about the substance abuse history of a driver / applicant, with focus on alcohol and drugs.

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The driver or applicant enters both driving and non-driving conviction history, including date and blood alcohol content or drug type. The second section includes entry methods for the evaluator to detail a lifetime history for alcohol and/or drug use and drug abuse disorders and problems, including program type (e.g., alcohol detoxification, residential / inpatient, intensive outpatient, outpatient (individual and/or group), education, driver safety intervention course, etc), lifetime drug and alcohol support group history details, and diagnostic impressions (DSM-IV).

Finally, there are sections for testing instrumentation, drug screening assessment, and lifetime abstinence history, as well as client drug and alcohol prognosis and continuum of care recommendations for drug and alcohol abuse problems. The evaluator and driver / applicant both have signature sections which can be required fields to ensure the complete submission of the form.

  • Signature Capture
  • Conditional Fields
  • Submission Editing
  • Reference Data
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