Wheelchair Assessment Form :: Jubilee Automotive Group Ltd

Today's date

Your full name

(please confirm your full name) e.g. Mr Robert Jones

Your phone number

(please confirm your best contact phone number)

Your email address

For the attention of ?

(please select a recipient for this enquiry)

Is the wheelchair powered or manual?

(please select whether the wheelchair is powered or manually propelled)

Wheelchair + occupant overall length (in millimetres mm)

(please confirm the overall length from the rearmost point of the wheelchair to the tip of the toes of the wheelchair occupant) typically 800 to 1400 (numbers only please)

Wheelchair + occupant, seated height (in millimetres mm)

(please enter the relaxed seated height of the wheelchair occupant) typically 900 to 1600 (numbers only please)

Wheelchair low level overall width (in millimetres mm)

(please enter the overall low level width of the wheelchair) typically 500 to 800

Clearance height of the foot pedestals (in millimetres mm)

(please confirm the maximum ground clearance of the foot pedestals) typically 60 to 300 (numbers only please)

Can the wheelchair occupant bend their head forward when initially accessing the vehicle?

(please confirm whether the wheelchair occupant can bend their head forward when initially entering the vehicle at the access point)

Comments

(please let us know any other relevant information)

Wheelchair Assessment Form

About the wheelchair & occupant

Enter your reg number