Wheelchair Skills Test Form – Fill Out and Use This PDF

Wheelchair Skills Test Questionnaire (WST-Q), Version 4.3

Scooters Operated by Their Users

Name of the wheelchair user: ___________________________ Date: ______________

Person completing questionnaire (if not user): _________________________________

Relationship between the wheelchair user and the person who helped him/her: _______

#	Individual Skill	Capacity	Confidence	Performance	Training
		(0-2)	(0-2)	(0-4)	Goal? (Y/N)
1	Moves controller away and back
2	Turns power on and off
3	Selects drive modes and speeds
4	Operates body positioning options
5	Disengages and engages motors
6	Operates battery charger
7	Rolls forwards short distance
8	Rolls backwards short distance
9	Turns in place
10	Turns while moving forwards
11	Turns while moving backwards
12	Maneuvers sideways
13	Reaches high object
14	Picks object from floor
15	Level transfer
16	Gets through hinged door
17	Rolls longer distance
18	Avoids moving obstacles
19	Ascends slight incline
20	Descends slight incline
21	Ascends steep incline
22	Descends steep incline
23	Rolls across side-slope
24	Rolls on soft surface
25	Gets over threshold
26	Gets over gap
27	Ascends low curb
28	Descends low curb
29	Gets from ground into wheelchair
	Total scores:	%

WST-Q 4.3 for Scooters Operated by Their Users

Originally approved for distribution and use: November 9, 2015; Current version: November 9, 2015

General comments:

Training goals described by the wheelchair user, other than those noted for specific skills:

Name and address of any person(s) to whom the test subject would like a copy of the report to be sent.

Details about the WST can be found in the WSP Manual at www.wheelchairskillsprogram.ca.

WST-Q 4.3 for Scooters Operated by Their Users

Originally approved for distribution and use: November 9, 2015; Current version: November 9, 2015