Centrica MyHealth - Vehicle Assessment Request Step 1 of 2 50% From time to time you may wish MyHealth to undertake a vehicle assessment for an employee. This is normally due to a number of reasons, including that the employee: Is above 6ft 2ins tall and may have difficulty driving the standard vehicle safely Has either long limbs or a long torso which may cause either unsafe practices or issues that may affect musculoskeletal function Has a medical condition where the vehicle may be causing them further harm Please complete the details below if, having followed the Back Care for Drivers Guide, your employee meets any of the above criteria or has another issue you feel necessitates a driver fitness assessment.Please also attach a photo of your employee sat in their current vehicle from a side on angle.We will not be able to book an employee in for an assessment without receiving the photo of them in their vehicle with their current set up. This is because it may negate the need for an assessment to take place which will save time and ensure that more appointments are available.Following the Driver Fitness Assessment, you will receive a report and recommendations including the most appropriate vehicle for the individual.If you require any further support, call MyHealth on 0333 577 1336 (1336) option 4 and ask to be transferred to a Functional Health specialist.Your detailsYour name* First Last Date of referral*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employee detailsEmployee name First Last Age Payroll number Height Centimeters (cm) Feet and Inches Feet Inches Metres Centimetres Weight Kilograms Stone Stone lbs Kgs Job detailsJob role Length of time in role Which vehicles are currently specified for the role?Which vehicle does the employee currently drive? Approximate hours driving per day (if known)Please enter a number from 0 to 24.Approximate hours driving per week (if known)Please enter a number from 0 to 168.Brief reason for referralHas the employee had a previous vehicle assessment? Yes No Date if knownDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What recommendations were made? Have you or a colleague undertaken an assessment of this employee in their vehicle? Yes No What were your findings? Is there any other information that may be relevant (e.g. history of injuries or accidents, known medical conditions)Please upload your photo here.Photo of employee from side on angleAccepted file types: pdf, jpg, jpeg, doc, docx, Max. file size: 2 MB.