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Wheelchair Skills Test Questionnaire (WST-Q) Version 5.3 for Manual Wheelchairs

Question Answer
Name of the wheelchair user?

Date questionnaire completed (month, day, year)?

Did you complete the questionnaire yourself? □ Yes

□ No
If you had help, what is the name of the person who
helped you?
If you had help, what is the relationship between you □ Family member
and the person who helped you? □ Friend
□ Caregiver
□ Other person
Do the answers for the questionnaire reflect your □ Alone
situation alone, or with the assistance of your □ Caregiver-assisted
caregiver (if any)

Introduction to the questionnaire

 Copies of this questionnaire can be downloaded from https://wheelchairskillsprogram.ca/en/skills-

manual-forms/.

 More details about the questionnaire can be found there in the WSP Manual.

 In this questionnaire, you will be asked questions about different skills that you might do in your
wheelchair. These skills range from ones that are more basic at the beginning to those that are more
advanced at the end.

 There are no “right” or “wrong” answers. The purpose of the questionnaire is simply to help us
understand how you use your wheelchair.

 It will probably take about 10 minutes to complete the questionnaire, but please take as much time as
you need.

 If you have more than one wheelchair, the questions are about the wheelchair that you use most often.

 If you have any comments, you will be able to record them at the end of the questionnaire.

 For each specific skill, beginning on page 3, you will be asked up to four questions. The questions
and the possible answers are shown below.

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
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 If one of the purposes of this questionnaire is to assess if you can perform each skill, you should
answer the following question:
Performance question: “Could you do this skill today in your own setting?”
Answer Score What this means
Yes, very well 3 I could do the skill safely and very well.
Yes, but not well 2 I could do the skill safely, but not well.
Yes, with help 1 I could do most, but not all, of the skill or I could direct a
stranger to help me do it.
No 0 I have never done the skill or could not do it right now.
No part NP The wheelchair does not have the parts to allow this skill. (This
option is only presented for skills where such a score is a
possibility.)

 If one of the purposes of this questionnaire is to assess how confident you are in performing each
skill, you should also answer the following question:
Confidence question: “How confident are you that you could you do this skill safely and
consistently today in your own setting?”
Answer Score What this means
Very confident 3 I am very confident.
Somewhat confident 2 I am somewhat confident.
Somewhat unconfident 1 I am somewhat unconfident.
Very unconfident 0 I am very unconfident.
No part NP The wheelchair does not have the parts to allow this skill. (This
option is only presented for skills where such a score is a
possibility.)

 If one of the purposes of this questionnaire is to assess how often you do each skill, you should also
answer the following question:
Frequency question: “How often do you do this skill in your own setting?”
Answer Score What this means
Always 3 Always when I need or want to do so.
Usually 2 Usually when I need or want to, but sometimes not.
Rarely 1 Rarely when I need or want to, but not usually.
Never 0 Never or less often than once a year.
No part NP The wheelchair does not have the parts to allow this skill. (This
option is only presented for skills where such a score is a
possibility.)

 If one of the purposes of this questionnaire is to assess if this skill is a training goal, you should also
answer the following question:

Goal question: “Is this a skill for which you would be interested in receiving training?”
Answer Score What this means
Yes Y I am interested in receiving training for this skill.
No N I am not interested in receiving training for this skill.

 Please read the questions about specific skills that begin on the next page. For each skill, record the
answers in the spaces provided.

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
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WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
 4

Questions on Specific Skills

Questions
(Pick only one answer for each question)
# Skill Description Could you do it How confident are How often Is this a
today? you? do you do it? training
goal?
1 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
forward, for □ Yes, with help confident □ Rarely
example along a □ No □ Somewhat □ Never
hallway. unconfident
□ Very unconfident
2 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
backward, for □ Yes, with help confident □ Rarely
example to back □ No □ Somewhat □ Never
away from a unconfident
table. □ Very unconfident
3 Turning the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
around in a small □ Yes, with help confident □ Rarely
space so that it is □ No □ Somewhat □ Never
facing in the unconfident
opposite □ Very unconfident
direction.
4 Turning the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
around obstacles □ Yes, with help confident □ Rarely
while moving □ No □ Somewhat □ Never
forward. unconfident
□ Very unconfident
5 Turning the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
around obstacles □ Yes, with help confident □ Rarely
while moving □ No □ Somewhat □ Never
backward. unconfident
□ Very unconfident

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
 5

Questions
(Pick only one answer for each question)
# Skill Description Can you do it? How confident are How often Is this a
you? do you do it? training
goal?
6 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
sideways in a □ Yes, with help confident □ Rarely
small space, for □ No □ Somewhat □ Never
example to get unconfident
the side of your □ Very unconfident
wheelchair next
to a kitchen
counter, and then
back to where
you started.
7 Picking a small □ Yes, very well □ Very confident □ Always □ Yes
object up from □ Yes, but not well □ Somewhat □ Usually □ No
the ground (for □ Yes, with help confident □ Rarely
example a cell □ No □ Somewhat □ Never
phone). Also, unconfident
reaching an □ Very unconfident
overhead object
(for example
something on a
shelf).
8 Operating all of □ Yes, very well □ Very confident □ Always □ Yes
the positioning □ Yes, but not well □ Somewhat □ Usually □ No
options of the □ Yes, with help confident □ Rarely
wheelchair (for □ No □ Somewhat □ Never
example tilting □ No part unconfident □ No part
the seat, reclining □ Very unconfident
the seat, □ No part
elevating the leg-
rests).
9 Shifting the □ Yes, very well □ Very confident □ Always □ Yes
weight from your □ Yes, but not well □ Somewhat □ Usually □ No
sitting surfaces. □ Yes, with help confident □ Rarely
□ No □ Somewhat □ Never
unconfident
□ Very unconfident

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
 6

Questions
(Pick only one answer for each question)
# Skill Description Can you do it? How confident are How often Is this a
you? do you do it? training
goal?
10 Transferring □ Yes, very well □ Very confident □ Always □ Yes
from the □ Yes, but not well □ Somewhat □ Usually □ No
wheelchair to a □ Yes, with help confident □ Rarely
bench that is □ No □ Somewhat □ Never
about the same unconfident
height as the □ Very unconfident
wheelchair and
then getting back
into the
wheelchair.
11 Folding your □ Yes, very well □ Very confident □ Always □ Yes
wheelchair or □ Yes, but not well □ Somewhat □ Usually □ No
taking it apart □ Yes, with help confident □ Rarely
without tools, for □ No □ Somewhat □ Never
example to store □ No part unconfident □ No part
it out of the way, □ Very unconfident
and then opening □ No part
or reassembling
it again.
12 Getting down on □ Yes, very well □ Very confident □ Always □ Yes
the ground, then □ Yes, but not well □ Somewhat □ Usually □ No
back into the □ Yes, with help confident □ Rarely
wheelchair. □ No □ Somewhat □ Never
unconfident
□ Very unconfident
13 Opening a hinged □ Yes, very well □ Very confident □ Always □ Yes
door, moving the □ Yes, but not well □ Somewhat □ Usually □ No
wheelchair □ Yes, with help confident □ Rarely
through it and □ No □ Somewhat □ Never
closing it behind unconfident
you, then coming □ Very unconfident
back the other
way.
14 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair up a □ Yes, but not well □ Somewhat □ Usually □ No
slight incline, for □ Yes, with help confident □ Rarely
example a □ No □ Somewhat □ Never
standard ramp. unconfident
□ Very unconfident

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
 7

Questions
(Pick only one answer for each question)
# Skill Can you do it? How confident are How often Is this a
Description you? do you do it? training
goal?
15 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
down a slight □ Yes, with help confident □ Rarely
incline under □ No □ Somewhat □ Never
control. unconfident
□ Very unconfident
16 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair up a □ Yes, but not well □ Somewhat □ Usually □ No
steep incline □ Yes, with help confident □ Rarely
(about twice as □ No □ Somewhat □ Never
steep as a unconfident
standard ramp). □ Very unconfident
17 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
down a steep □ Yes, with help confident □ Rarely
incline under □ No □ Somewhat □ Never
control. unconfident
□ Very unconfident
18 Moving the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair □ Yes, but not well □ Somewhat □ Usually □ No
across a soft □ Yes, with help confident □ Rarely
surface, for □ No □ Somewhat □ Never
example grass. unconfident
□ Very unconfident
19 Getting the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair over □ Yes, but not well □ Somewhat □ Usually □ No
an obstacle that □ Yes, with help confident □ Rarely
sticks up above □ No □ Somewhat □ Never
the surface, for unconfident
example a high □ Very unconfident
door threshold.
20 Getting the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair up a □ Yes, but not well □ Somewhat □ Usually □ No
low curb, for □ Yes, with help confident □ Rarely
example when □ No □ Somewhat □ Never
entering a unconfident
building. □ Very unconfident

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
 8

Questions
(Pick only one answer for each question)
# Skill Description Can you do it? How confident are How often Is this a
you? do you do it? training
goal?
21 Getting the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair down □ Yes, but not well □ Somewhat □ Usually □ No
from a low curb. □ Yes, with help confident □ Rarely
□ No □ Somewhat □ Never
unconfident
□ Very unconfident
22 Getting the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair up a □ Yes, but not well □ Somewhat □ Usually □ No
high curb, for □ Yes, with help confident □ Rarely
example at a □ No □ Somewhat □ Never
street corner unconfident
without a ramp. □ Very unconfident
23 Getting the □ Yes, very well □ Very confident □ Always □ Yes
wheelchair down □ Yes, but not well □ Somewhat □ Usually □ No
from a high curb. □ Yes, with help confident □ Rarely
□ No □ Somewhat □ Never
unconfident
□ Very unconfident
24 Doing a wheelie, □ Yes, very well □ Very confident □ Always □ Yes
balancing the □ Yes, but not well □ Somewhat □ Usually □ No
wheelchair on its □ Yes, with help confident □ Rarely
rear wheels. □ No □ Somewhat □ Never
unconfident
□ Very unconfident
25 Staying in a □ Yes, very well □ Very confident □ Always □ Yes
wheelie, turning □ Yes, but not well □ Somewhat □ Usually □ No
the wheelchair □ Yes, with help confident □ Rarely
around in a small □ No □ Somewhat □ Never
space so that it is unconfident
facing in the □ Very unconfident
opposite
direction.
26 Moving forward □ Yes, very well □ Very confident □ Always □ Yes
and backward in □ Yes, but not well □ Somewhat □ Usually □ No
the wheelie □ Yes, with help confident □ Rarely
position. □ No □ Somewhat □ Never
unconfident
□ Very unconfident

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022
 9

Questions
(Pick only one answer for each question)
# Skill Can you do it? How confident are How often Is this a
Description you? do you do it? training
goal?
27 Staying in a □ Yes, very well □ Very confident □ Always □ Yes
wheelie, moving □ Yes, but not well □ Somewhat □ Usually □ No
forwards down a □ Yes, with help confident □ Rarely
high curb. □ No □ Somewhat □ Never
unconfident
□ Very unconfident
28 Staying in a □ Yes, very well □ Very confident □ Always □ Yes
wheelie, moving □ Yes, but not well □ Somewhat □ Usually □ No
forwards down a □ Yes, with help confident □ Rarely
steep incline. □ No □ Somewhat □ Never
unconfident
□ Very unconfident
29 Getting yourself □ Yes, very well □ Very confident □ Always □ Yes
and the □ Yes, but not well □ Somewhat □ Usually □ No
wheelchair up a □ Yes, with help confident □ Rarely
short flight of □ No □ Somewhat □ Never
stairs. unconfident
□ Very unconfident
30 Getting yourself □ Yes, very well □ Very confident □ Always □ Yes
and the □ Yes, but not well □ Somewhat □ Usually □ No
wheelchair □ Yes, with help confident □ Rarely
down a short □ No □ Somewhat □ Never
flight of stairs. unconfident
□ Very unconfident

If you have any general comments about the questions that you have answered above, please record them
in the space available below.

This is the end of the questionnaire. Thank you for completing it.

WST-Q 5.2 for Manual Wheelchairs

Originally approved for distribution and use: August 19, 2022
Current version: August 19, 2022