Manual Wheelchair User Survey
1.
What is the make (manufacturer) and model of your current wheelchair?
Make
Model
2.
What casters are on your
manual
wheelchair?
3 x 1 Roller Blade Casters
4 x 1 Roller Blade Casters
4 x 1 Soft Roll Casters
4 x 1 Frog Legs Soft Roll Casters
4 x 1 Aluminum Micro Casters
4 x 1 ½ Machined Aluminum Casters
5 x 1 Poly Casters
5 x 1 Soft Roll Casters
5 x 1 Frog Legs Soft Roll Casters
5 x 1 Machined Aluminum Casters
5 x 1 ½ Poly Casters
5 x 1 ½ Machined Aluminum Casters
6 x 1 ¼ Soft Roll Casters
6 x 1 ¼ Pneumatic (air up) Casters
6 x 1 ½ Poly Casters
6 x 1 ½ Machined Aluminum Casters
8 x 1 Poly Casters
8 x 1 ¼ Soft Roll Casters
8 x 1 ¼ Pneumatic (air up) Casters
3.
What types of caster related problems have you experienced (Check all that apply)?
Frequent air loss and/or flats on pneumatic (air up) tires
Tires wear out
Tire roll-off (i.e. tire rolls off the caster or tire rolls off the drive wheel)
Caster shimmy (i.e. the casters or drive wheels wiggle when you roll)
Caster material cracks, breaks, peels apart or shreds
Casters or drive wheels leave marks on carpet or other types of flooring
Foreign matter (i.e. hair, thread, dirt, etc.) gets caught in casters
Caster bolts and nuts loosen up
Bearings wear out and/or freeze-up
Fork or caster breaks
4.
Number the following surfaces according to the difficulty you experience when pushing/rolling over them
1 is most difficult, 9 is the easiest.
1
2
3
4
5
6
7
8
9
Carpet or rugs
Hardwood or vinyl flooring
Rubber flooring or rubber mats
Grass
Gravel or loose dirt
Wet surfaces
Concrete sidewalk
Icy surfaces
Asphalt
5.
Which surface causes the most damage to your casters?
Carpet or rugs
Gravel or loose dirt
Rubber flooring or rubber mats
Grass
Hardwood or vinyl flooring
Wet surfaces
Concrete sidewalk
Icy surfaces
Asphalt
6.
How often are the casters on your wheelchair replaced?
Every 6 months
Every 9 months
Every year
Every year and a half
Every two years
Every two and a half years
Every three years
7
.
How often are the drive wheels on your
manual
wheelchair replaced?
Every 6 months
Every 9 months
Every year
Every year and a half
Every two years
Every two and a half years
Every three years
8.
Who participated in the selection of the casters a for your manual wheelchair?
Myself
Therapist
Vendor
Nurse
9.
What factors were used for the selection of the casters?
For function
Special needs
Cost
None
10.
How are replacement casters on your wheelchair paid for?
Private Insurance
Medicare
Out-of-pocket/ personal funds
State Medicaid
11.
How much do you spend out-of-pocket (using personal funds) on casters?
Dollar Amount $
per (time frame)
12.
What caster effects and colors do you prefer?
1 is most desirable, 7 is the least.
1
2
3
4
5
6
7
Black
Blue
Green
Orange
Grey
Red
Yellow
Clear
Lighted
13.
What front suspension system do you have on your current wheelchair?
Frog Legs
Frog Legs Uni-Tine Forks
Bull Frogs
None
14.
What is your gender?
Male
Female
15.
What is your ethnicity?
Asian, Asian Indian or Pacific Islander
Black or African-American
Hispanic or Latino
Native American or Alaskan Native
White/Caucasian
Other
16.
Where is your home located?
Rural community/in the country
Small to mid-sized town
Suburban neighborhood
Urban neighborhood/inner city
17.
What is your current level of employment? (Check all that apply)
Employed full-time
Employed part-time
Parenting/Homemaker
Full-time student
Part-time student
Unemployed
Unable to work
18.
What is the highest level of education you have completed?
No high school
Some high school
High school diploma or GED
Completed 1-3 years of college (i.e. an associate’s or technical degree)
Completed four-year bachelor’s degree
Some graduate work
Completed master’s
Completed doctorate
Completed professional degree such as MD, JD, RN
Other
19.
What is your total average monthly household income?
Less than $600
$600-$1199
$1200-$1999
$2000-$2999
$3000-$4999
$5000 or more
20.
How do you rate your weekly activity level? Are you
not very active
(unemployed, leave home once per day, move around inside)
moderately active
(at least a part-time employee or student, leave home more than once per day and move around outside home, access community services outside home)
active
(full-time employee or student, leave home more than once per day, more around outside the home, access community services)
very active
(in addition to “active,” play a sport like wheelchair basketball or tennis at least once per week)
21.
Additional C
omments:
Powered by SurveySolutions
survey software
