Your Whizz Kidz Wheelchair

Thank you for completing this survey. Your feedback is important to us and will help us improve services and demonstrate the impact we have to our funders.

The information you provide in the survey will be kept anonymous. Any comments or feedback we share will not include your name or any personal or identifying features.

Whizz-Kidz promises to look after your personal information. For more information please see Whizz-Kidz’s privacy policy here: www.whizz-kidz.org.uk/privacy.

Whizz-Kidz are using Jotform to collect information on this form. You can read Jotform’s privacy policy here: https://www.jotform.com/privacy/.

Name / Name of young person (if completing on behalf of you child or young person)

How comfortable were you sitting in your previous wheelchair and now in your Whizz Kidz wheelchair where 0 = Not comfortable at all and 10 = Very comfortable?

	Your previous wheelchair	Your Whizz Kidz wheelchair
Service Quality

How satisfied were you with how you were sitting in your previous wheelchair and now in your Whizz Kidz wheelchair where 0 = Not satisfied at all and 10 = Very satisfied?

	Your previous wheelchair	Your Whizz Kidz wheelchair
Service Quality

Please choose up to 5 activities that are important to you to do around your home and in your community and score how satisfied (or pleased) you were doing each activity with your previous wheelchair and now with your Whizz Kidz wheelchair.

These can be activities you enjoy doing or activities you wanted to do but found difficult before you received your Whizz Kidz wheelchair such as going in the garden, playing games, making snacks, going to school, shopping, hanging out with friends, using public transport etc…

	Please tell us up to 5 activities you enjoy doing	Score: your previous wheelchair	Score: your Whizz Kidz wheelchair
Service Quality
Cleanliness
Responsiveness
Friendliness
fifth

Please score the following statements out of 10 where 0 is not at all and 10 is loads!

Receiving my Whizz Kidz wheelchair has…

Given me increased independence

Given me increased confidence

Improved my wellbeing

We know that getting the right wheelchair means different things to everyone. Please can you give us an example of how your new wheelchair has made a difference to your independence, confidence or wellbeing.

Is there anything else you would like to tell us?

Whizz Kidz Mobility Equipment

Comfort and Posture

Doing activities

About you

And Finally...