Exit this survey Partner Inventory 1. Default Section 100% of survey complete. Question Title * 1. Please let us know what organization you are representing and who you are. Name: * Company: * Address: Address 2: City/Town: State: ZIP/Postal Code: Country: * Email Address: * Phone Number: * Question Title * 2. What container/ PO Number are you reporting on? Question Title * 3. How many Gen_1 wheelchairs do you currently have in your warehouse/ storage facility? 0 1- 100 101 - 250 251 - 500 501 - 1000 Other (please specify) Question Title * 4. How many Gen_2 wheelchairs do you currently have in your warehouse/storage facility? 0 1 - 100 101 - 250 251 - 500 501 - 1000 Question Title * 5. How many recipient applications are currently backlogged or cleared to receive wheelchairs? 0 - 100 101 - 300 301 - 500 501 - 700 700 - 1000 1001+ Other (please specify) Question Title * 6. What is your current inventory of spare parts? Plastic Seats Castor Wheels Brakes Axles Axle Plates Rear Wheels Hardware Question Title * 7. How many service requests have you received and fulfilled and what was the nature of the request? Number of Requests Received Number of Requested Fulfilled Castor Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Castor Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Castor Replacement Number of Requested Fulfilled menu Inner Tube Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Inner Tube Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Inner Tube Replacement Number of Requested Fulfilled menu Rear Wheel Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Rear Wheel Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Rear Wheel Replacement Number of Requested Fulfilled menu Plastic Chair Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Plastic Chair Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Plastic Chair Replacement Number of Requested Fulfilled menu Axle Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Axle Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Axle Replacement Number of Requested Fulfilled menu Axle Plates Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Axle Plates Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Axle Plates Replacement Number of Requested Fulfilled menu Hardware Replacement 1 - 5 6 - 15 16 - 30 31 - 50 51+ Hardware Replacement Number of Requests Received menu 1 - 5 6 - 15 16 - 30 31 - 50 51+ Hardware Replacement Number of Requested Fulfilled menu Other (please specify) Question Title * 8. We do not currently provide extras of the listed items, however please let us know if you've received requests for any of these items to be repaired or replaced so we can consider sending them in the future. Cushions Footrests Footplates Frames Hand Pumps Patch Kits Harnesses Other (please specify) Question Title * 9. Have you had any reports of injury from use of the wheelchair? Yes No Question Title * 10. If you have received reports of injury, please identify the issue and estimated number of reported calls. 1 - 5 6 - 10 11 - 15 16 - 20 21 - 25 26+ Pressure Sores Pressure Sores 1 - 5 Pressure Sores 6 - 10 Pressure Sores 11 - 15 Pressure Sores 16 - 20 Pressure Sores 21 - 25 Pressure Sores 26+ Injured getting into chair Injured getting into chair 1 - 5 Injured getting into chair 6 - 10 Injured getting into chair 11 - 15 Injured getting into chair 16 - 20 Injured getting into chair 21 - 25 Injured getting into chair 26+ Injured getting out of chair Injured getting out of chair 1 - 5 Injured getting out of chair 6 - 10 Injured getting out of chair 11 - 15 Injured getting out of chair 16 - 20 Injured getting out of chair 21 - 25 Injured getting out of chair 26+ Injured due to wheelchair tip over Injured due to wheelchair tip over 1 - 5 Injured due to wheelchair tip over 6 - 10 Injured due to wheelchair tip over 11 - 15 Injured due to wheelchair tip over 16 - 20 Injured due to wheelchair tip over 21 - 25 Injured due to wheelchair tip over 26+ Other (please specify) Question Title * 11. Have you had any reports of reipient deaths? Yes No Question Title * 12. If deaths have been reported, please describe, if possible, the cause(s) of death(s). Question Title * 13. In most cases when a recipient death is reported, what becomes of the wheelchair that was given to them? Wheelchair returned to Partner Wheelchair picked up by Partner Wheelchair kept by Family Unknown Other (please specify) Question Title * 14. Did your organization distribute the User Manual to all recipients during the distribution of wheelchairs? Yes No Question Title * 15. How often did representatives from your organization present a training and or show the training video during distributions? 100% 80-99% 60-79% 40-59% 20-39% 0-19% Other (please specify) Question Title * 16. Did the appropiate staff/ volunteers view the training video prior to giving the training to recipients? Yes No Not sure Other (please specify) Question Title * 17. Did your representatives allow time for the recipients to ask questions following the training? Yes No Not Sure Other (please specify) Question Title * 18. What was the recipient's level of interest and understanding in the presentation of the training? Excellent Good Fair Poor Interest in the presentation Interest in the presentation Excellent Interest in the presentation Good Interest in the presentation Fair Interest in the presentation Poor Understanding of the presentation Understanding of the presentation Excellent Understanding of the presentation Good Understanding of the presentation Fair Understanding of the presentation Poor Question Title * 19. How helpful do you think this manual will be to the recipients? Extremely Very Average Ok Not at all Other (please specify) Question Title * 20. What suggestions do you have for Free Wheelchair Mission, in efforts for us to improve the training program and manual? Done
