Mobility for Life
Power Wheelchair specification form

Assessment date: Date

I confirm that I have informed the individual that their information is being collected by me and will be provided to Enable New Zealand for the purposes described in this form, including assessment, funding, equipment provision and oversight, as part of the Mobility for Life project.

Person’s details
Last name	Last name	First name(s)	First name
NHI number	NHI	Date of birth	Date of birth
Phone number	Phone number	Email address	Email address

EMS Assessor’s details
Assessor name	Name	AEA number	AEA number
Phone number	Phone number	Email address	Email address
Accreditation	Choose an accreditation credential
Preferred method of contact	Choose a method of contact

Delivery details for Power Wheelchair
Delivery address	Delivery address
Phone contact	Delivery phone number

Power wheelchair details

Occupant weight: Weight

Feature	Selection
WMPML1 credentialing required	WMPML2 credentialing required
Drive wheel location and size Note your preference in the ‘Other Requirements’ section if more than one drive wheel configuration is selected.	Location Rear-wheel drive Mid-wheel drive Front-wheel drive Size of drive wheel 10” 12-13” 14”
Seat width	Seat width set at: seat width Maximum seat adjustment (if required): max width adjustment
Effective seat depth	Effective seat depth set at: seat depth Maximum seat adjustment (if required): max depth adjustment
Power seat functions	Power posterior tilt	Power seat elevation Power recline Power anterior tilt, required angle: anterior tilt angle Power standing
Floor to seat pan	15-16.75” 17-17.75” 18-18.75” 19-19.75” specific height
Max overall width If essential, note in ‘Other Requirements’.	Max width
Controller	Left side Right side Swing-away/retractable	Alternative switch / driving control Add details in ‘Other Requirements’ section below, eg head array, chin control etc.
Electronics	Non-expandable	Expandable
Back configuration	No upholstery Angle adjustable back posts Extended back post height set at: height
Lower leg support assembly	70˚ Swing-away 80˚ Swing-away Centre mount / flip-up Manual elevating	Power elevating lower leg support: Centre mount Swing-away Specify if elevating lower leg supports need to elevate and articulate, or elevate, articulate, and lower to the ground in ‘Other Requirements’ section below.
Seat pan to foot support (excluding cushion thickness)	Seat pan to foot support measurement: measurement ¨ Angle adjustable foot support ¨ Standard foot support ¨ Posterior foot support (heel loops)
Stump support	¨ Left ¨ Right ¨ both
Arm support assembly	Desk Full length Flip-up Drop-in Dual post flip-up Adult Pediatric
Accessories / Secondary seating supports	Pelvic Positioning Belt: Standard 2 point padded 4 point padded Pelvic Positioning Belt size: Small Medium Large Tyres: Pneumatic Solid Lights

Other requirements

Add details and rationale for any features or modifications required to the wheelchair that are not included above or related to the seating system, but only if this impacts the final configuration of the wheelchair.

Include specific requirements of selections like elevating lower leg supports and alternative switch/drive control.

Details of other requirements
Details of other requirements