Resident Name: ______________________ Room: ____________ Date: _____
Ask the resident and staff to give you the wheelchair at a time when it is not in use by the resident. There are seven parts to the Engineer Wheelchair Inspection. Each part has instructions to follow. Refer to the wheelchair diagram at the end of this form. Put a check in the box beside all of the tasks which need to be done. All wheelchairs should be inspected at least every six months. Keep this form for your records so that you know when this wheelchair was last inspected. Use this form each time you repeat the assessment. When you have done the task, write your initials beside it.
Section 1. General Cleaning and Lubrication
Inspect the joints to see if they are dry. Check the chair for dirt and dust.
___ If dirty, clean all parts of chair with soap and water. Wipe clean.
___ If slide does not move smoothly when you fold chair, spray slide post and into slide tube. Use white lithium, silicone, or teflon-based spray grease (not WD-40).
___ If joints are dry, spray with silicone.
Section 2. Frame Check
Check for loose fasteners, stripped screws, burrs on screwheads, center pin, bottom rail plug, seat rail guide tips, and spring catch. Choose a level surface and roll the chair. If the chair veers off to one side more than 1 foot as it moves forward 10 feet, check the frame for damage. Inspect the fork and stem of the casters for bent condition.
___ If fasteners are loose, tighten. If screws are missing, replace.
___ If there are burrs on the screwheads, file or sand burrs.
___ If center pin is worn, missing, or bent, replace or contact dealer.
___ If rail guide tips or rail plugs are worn, replace.
___ If rail posts are bent or cracked, replace.
___ If frame has crack or loose weld, repair right away or return to dealer.
___ If lifting straps are worn or broken, replace.
___ If spring catch is broken, replace.
Section 3. Wheel and Caster Check
Watch for side play of the wheels and casters while the chair is moving. Strum the spokes to check that they have been evenly tightened. Inspect the hubcaps, handrims, axles, stem bearings, washers and spoke guard. Check if the tire is on the rim. Use a tire gauge to check tire pressure if the tire is air-filled. If it is low, look for leaks. Inspect solid tires for cracks or worn areas. Check the casters for free movement.
___ If axle nut or bolt is loose, tighten.
___ If bearings, nuts, or washers are missing or worn, replace. If spoke guard is worn, replace.
___ If wheel spokes have uneven tightness, tighten evenly around wheel.
___ If edges of handrims or attaching hardware are rough, file or sand them.
___ If handrim is loose, attach securely. If rivets on handrim are loose, contact dealer.
___ If rubber tips are missing or worn, replace.
___ If fork or stem bearing is worn or bent, replace.
___ If felt washer or string guard is worn or missing, replace.
___ If casters are worn, cracked or uneven, replace.
___ If casters do not move freely because of dirt and grime, remove and clean.
___ If air-filled tire is soft, inflate until firm and at the pressure recommended on side of tire.
___ Repair leaks.
___ If solid tire is cracked or worn, replace.
Section 4. Brake Check
The tires must be filled to the correct pressure before checking brakes. Lock and unlock the brakes. Check if the brakes engage the tire 1/8 inch when locked and if they hold the chair in place. Check if the brake handles have rubber tips and inspect the latch and lever for wear.
___ If brake is loose, tighten. If brake cannot be tightened, replace.
___ If brake cannot be made to hold chair, change position of brake on frame tubing.
___ If lever or latch is worn, replace.
___ If rubber tip on brake end is worn or missing, replace or change when adding brake extension.
Section 5. Armrest Check
Check both armrests for padding, sharp edges, screws which stick out, and cracks or tears in cover. Check if the armrests are secure and all fasteners are tight. Check if the front and back posts fit into the frame.
___ If armrests wobble, tighten screws.
___ If cover is cracked, replace.
___ If armrests have sharp edges, file or sand.
___ If screws stick out through padding, replace.
___ If front or back posts do not fit into frame, repair or replace.
Section 6. Seat and Back Upholstery Check
Inspect the upholstery for cracks, tears and sagging. Check for missing hardware.
___ If hardware is loose or missing, tighten or replace.
___ If seat or back upholstery is cracked or torn, replace.
___ If back upholstery sags, contact Fall Prevention Therapist for instructions.
Section 7. Footrest and Legrest Check
Check the distance the footrest is away from the floor. Check if the spring holds the foot plate in all directions. Lock the legrest. Check if the length-adjustment hardware is secure. Inspect the legrest panels and straps for sharp edges, splits, or fraying. Inspect the heel loops for tears or fraying.
___ If lock for legrest does not adjust or is not secure, replace.
___ If fasteners are loose, tighten.
___ If edges are sharp, file or sand.
___ If leg panel is cracked, split or frayed, replace.
___ If nut to length adjustment hardware is loose or missing, replace.
___ If bumper tips on front extensions of legrest bar are missing, replace.
___ If heel loops on foot plate are worn, frayed or missing, replace.
___ If spring of foot plate is missing or worn, replace.
Signature: _________________________________________________________________
