CENTER FOR INDEPENDENT LIVING WHEELCHAIR AND SCOOTER REPAIR SURVEY

CIL is doing this confidential survey to determine the unmet needs of the local community of wheelchair or scooter users related to repair. Please email CILsurvey@yahoo.com or call CIL at (510) 841-4776 if you need assistance in obtaining or completing the survey.

After you submit the survey, you will have a chance to enter a drawing for a $50 gift certificate from Amazon, Safeway, Berkeley Bowl, or Whole Foods.

How many hours a day do you use a wheelchair or scooter?

0-5 hours
6-9 hours
10 or more hours

What is the brand of the wheelchair or scooter you use the most (see the label on your wheelchair or scooter, if unsure):

Action/Invacare
Colours
Everest and Jennings
Kuschall
Otto Bock
Permobil
Pride
Sunrise/Quickie
TiSport
Other: Please list

How old is your wheelchair or scooter?

1 year
2 years
3 years
4 years
5 years
6 years or older

What type of chair is this?

Power wheelchair
Manual wheelchair
Scooter

How many times in the past 6 months has the wheelchair or scooter you use most been repaired?

0
1
2
3
4 or more

Have any of these things happened to you in the past 6 months? (Check all that have happened.)

I have been stranded away from home for an hour or more, because of a wheelchair or scooter breakdown.
I have been unable to leave home, for 4 hours or more.
I have been injured because of a wheelchair or scooter breakdown.
I have missed work or school because of a wheelchair or scooter breakdown.
I have missed medical appointments because of a wheelchair or scooter breakdown.
I needed a loaner chair for the time of the repair, but was unable to get one.
I was unable to pay for the cost of the repair
Repairs were done, without any of the consequences listed above.

What type of repairs, if any, have you needed in the past 6 months? (Check all that apply.)

Battery or battery connections
Bearings
Brakes
Cushion, seating, upholstery
Electrical ( joy stick, switches, control box, etc.)
Frame (leg rest, back rest, arm rest, etc.)
Mechanical (drive belts or motor, gearbox, etc.)
Tires or tubes
Wheels
Other:

Who has repaired this wheelchair or scooter in the past 6 months? (Check all that apply.)

Bike shop
Grandmar/ CHME
Johnston Orthopedic, Berkeley
Residential Medical Systems, Oakland
Self/ Family Member/ Caregiver
National Seating and Mobility
Wheelchairs of Berkeley
Western Rehab Solutions, Martinez
Other technician/shop:

Who paid for this repair? (Check all that apply.)

Employer-provided, Personal Health Insurance, Personal Disability Insurance, or Workers' Compensation
Medicaid/Medicare
VA
Vocational Rehabilitation
Self or Family Member
Other (please explain):

If you had repairs in the last six months, have you experienced problems with any of the following (Check all that apply):

Quality of the repair
Price of the repair and/or billing practices
Pick up and drop off of the wheelchair or scooter
Quality of the service; how you were treated
Scheduling the repair
Amount of time it took to complete the repair
Availability of a loaner chair
Other:

If you'd like, tell us more about any recent problems you have had:

Would you be interested in learning more about wheelchair maintenance?

Yes, for power chairs
Yes, for manual chairs
No

Do you have any suggestions for improving services related to wheelchair or scooter repair in the East Bay?

Please tell us a bit about yourself (or the wheelchair or scooter user):

Zip Code of Residence:

Age:

0-17
18-34
35-64
65+

Gender:

Female
Male
Other

Disability (optional):

Arthritis
Cerebral Palsy (CP)
Multiple Sclerosis
Post polio
Spinal Cord Injury
Other:

Thank you!