Questionaire

SURVEY - AUTOMATICALLY GUIDED WHEELCHAIR

Part I. The following questions pertain to patients who cannot use a manual wheelchair:

1. How many patients of your institution are regular users of a power wheelchair? ______

Of these individuals, what percentage use each of the following power wheelchair control mechanisms:

joystick         ____% sip and puff ____%

chin control     ____% head control ____%

eye gaze control ____% other        ____%

(if other, please describe) ________________________________

2. How many patients are trained annually by staff of your facility to use a power wheelchair?

___ males,   age range: ____ average age ______

___ females, age range: ____ average age ______

3. At the conclusion of training, what percentage of these individuals

have no difficulty using a power wheelchair in activities of daily living (ADL)? ____%

have moderate difficulty using a power wheelchair in ADL? ____%

have extreme difficulty using a power wheelchair in ADL? ____%

find it impossible for practical purposes to use a power wheelchair in ADL? ____%

4. What percentage of your power wheelchair users have some difficulty with wheelchair maneuvering tasks, e.g. steering the chair through doorways, on/off elevators, or within the confines of a typical home or office? ____%

What percentage find it impossible to accomplish some or all of these maneuvering tasks without assistance? ____%

5. How many patients do you see annually who cannot use a power wheelchair because they lack the motor skills, strength, or visual acuity needed to control the chair? ____

What percentage of these patients do you feel could benefit from a computer-controlled wheelchair such as the one described in the accompanying video tape? (Assume the guidance system is "reasonably" priced and can be retrofitted to the power wheelchair of the patient's choice without interfering with necessary seating and positioning aids.) ____%

Part II. The following question pertains to patients with lower limb disabilities and cognitive impairment:

1. Assume that a reasonably priced computer-controlled wheelchair was available for cognitively impaired patients which would transport them unassisted to pre-programmed locations at individually pre-programmed times (for example, to the nurse's station to receive medications, to dining room at meal times, to clinic for therapy appointments, etc.) Do you perceive that such a device would be

(please
check
one) not at all useful.
useful only in a very small number of cases.
useful for many wheelchair restricted patients with cognitive disabilities.

Part III. The following questions pertain to all patients:

1. In your opinion, patients with what types of disabilities (or combinations of disabilities) would most benefit from a computer-controlled wheelchair navigation system similar to the one described in the accompanying video tape?

___________________________________________________

___________________________________________________

___________________________________________________

How many of these patients does your facility treat annually? _______

2. In order to be optimally beneficial to your patients, what operating characteristics would you consider essential to a computer-controlled wheelchair navigation system similar to the one described in the accompanying video tape?

___________________________________________________

___________________________________________________

___________________________________________________

Please return survey within 10 days of receipt to:
Linda Fehr, M.S.
Hines VA Hospital
Rehabilitation Research and Development Center 151L
P.O. Box 20
Hines, IL 60141

or fax survey to 1-708-531-7960

Thank you for your help!

SURVEY - AUTOMATICALLY GUIDED WHEELCHAIR

Part I. The following questions pertain to patients who cannot use a manual wheelchair:

1.	How many patients of your institution are regular users of a power wheelchair? ______

	Of these individuals, what percentage use each of the following power wheelchair control mechanisms:
		joystick ____%	sip and puff ____%
		chin control ____%	head control ____%
		eye gaze control ____%	other ____%
	(if other, please describe)	________________________________

2.	How many patients are trained annually by staff of your facility to use a power wheelchair?
	___ males, age range: ____	average age ______
	___ females, age range: ____	average age ______

3.	At the conclusion of training, what percentage of these individuals
	have no difficulty using a power wheelchair in activities of daily living (ADL)?	____%
	have moderate difficulty using a power wheelchair in ADL?	____%
	have extreme difficulty using a power wheelchair in ADL?	____%
	find it impossible for practical purposes to use a power wheelchair in ADL?	____%

4.	What percentage of your power wheelchair users have some difficulty with wheelchair maneuvering tasks, e.g. steering the chair through doorways, on/off elevators, or within the confines of a typical home or office?	____%

	What percentage find it impossible to accomplish some or all of these maneuvering tasks without assistance?	____%

5.	How many patients do you see annually who cannot use a power wheelchair because they lack the motor skills, strength, or visual acuity needed to control the chair?	____

	What percentage of these patients do you feel could benefit from a computer-controlled wheelchair such as the one described in the accompanying video tape? (Assume the guidance system is "reasonably" priced and can be retrofitted to the power wheelchair of the patient's choice without interfering with necessary seating and positioning aids.)	____%


Part II. The following question pertains to patients with lower limb disabilities and cognitive impairment:

1.	Assume that a reasonably priced computer-controlled wheelchair was available for cognitively impaired patients which would transport them unassisted to pre-programmed locations at individually pre-programmed times (for example, to the nurse's station to receive medications, to dining room at meal times, to clinic for therapy appointments, etc.) Do you perceive that such a device would be

	(please check one)	not at all useful. useful only in a very small number of cases. useful for many wheelchair restricted patients with cognitive disabilities.


Part III. The following questions pertain to all patients:

1.	In your opinion, patients with what types of disabilities (or combinations of disabilities) would most benefit from a computer-controlled wheelchair navigation system similar to the one described in the accompanying video tape?
	___________________________________________________
	___________________________________________________
	___________________________________________________

	How many of these patients does your facility treat annually?	_______

2.	In order to be optimally beneficial to your patients, what operating characteristics would you consider essential to a computer-controlled wheelchair navigation system similar to the one described in the accompanying video tape?
	___________________________________________________
	___________________________________________________
	___________________________________________________

Please return survey within 10 days of receipt to: Linda Fehr, M.S. Hines VA Hospital Rehabilitation Research and Development Center 151L P.O. Box 20 Hines, IL 60141 or fax survey to 1-708-531-7960
Thank you for your help!

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Last revised Wed 02/16/2000