Survey Templates Surveys Wheelchair Restraints

Wheelchair Restraints

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The following survey has been put together by students involved in a senior design project at the University of Wisconsin Madison. We need your help by completing our survey. The results will assist us in improving wheelchair occupant restraint systems. Thank you.

1.Gender:

Male

Female

2.What is your age?

What is your weight? (lbs.)

4.What is your height in inches? (ex. 5 feet 10 inches = 70 inches)

Which of the following best describes you?

Wheelchair user

Caregiver of a wheelchair user

Other

What type of wheelchair do you primarily use?

Rigid Manual Wheelchair

Folding Manual Wheelchair

Power Wheelchair

Power Scooter

Other

7.Which of the following best describes how you travel?

Remain in own wheelchair while drving

Transfer to standard car seat while driving

Use private transportation van

Use public transportation

Other

What type of safety belt do you use while in transit?

I don't wear a safety belt

I use a lap belt that is attached to my wheelchair.

I use a lap belt that is attached to the vehicle

I use a shoulder belt that is attached to the vehicle

I use a shoulder belt that is attached to both my wheelchair and the vehicle

I use a lap and shoulder belt that are attached to my wheelchair

Other

Do you use a safety restraint in day to day use? (not in vehicle transit)

Yes

Have you ever fallen out of your wheelchiar?

Yes

Were you in a vehicle when you fell from your chair?

Yes

What type of injury did you sustain when you fell from your wheelchair?

No Injury

Mild Injury

Severe Injury

Other

How much assistance do you need when using a safety belt in a vehicle.

I don't need any assistance

I need help latching the belt

I need help disconnecting the belt

I need help reaching the belts in a vehicle

I need help using the lap belt

I need help using the shoulder belt

I don't use safety belts

Other

Check the following that apply to you

I feel safe, secure, and supported when using a safety belt

I am required to use a safety belt in the vehicle that I travel in

The structure of my wheelchair interferes with using a safety belt

It takes too much time to fasten a safety belt

Shoulder belts are uncomfortable

Lap belts are uncomfortable

Shoulder belts fit me snugly

Lap belts fit me snugly

If safety belts fit better, I would use them

What types of accessories do you normally have attached to your wheelchair.

Lap belt

Shoulder belt

Harness

Padded leg supports

Armrests

Headrest

Headband

Backpack

Lap tray

Other

Which of the following do you prefer?

A safety belt attached to my wheelchair

A safety belt attached to my vehicle

No preference

17.Rate the importance of the following features of your wheelchair restraint system

	Most Important	Important	Somewhat Importatnt	Not Important	Neutral
Belt comfort/fit	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Crash protection	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Independent use/ease of use	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Low maintenance	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Low cost	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Provides body support	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Low weight	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

Appearance	Most Important	Important	Somewhat Importatnt	Not Important	Neutral

18.Rate the following

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Restraints are important in vehicle transit	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree

Restraints are important for daily use	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree

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Wheelchair Restraints

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