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Application Form

Wheelchair Baby Carrier Testing

Thank you for your interest in taking part in our research.

Designability is developing a pushchair that attaches to manual wheelchairs. We are looking to engage with manual wheelchair users who would be interested in testing our new prototype with their manual wheelchair.

Please complete this form to register your interest in testing the wheelchair baby carrier prototype in Bath.

Your information will be treated confidentially and will only be used in relation to this project.

If you would like to get in touch about this project, please email us at wheelchairbabycarrier@designability.org.uk
Taking part
Please fill in the following information to confirm you can take part.
1.Please confirm that you are a manual wheelchair user 

(the wheelchair baby carrier is not suitable for powered wheelchairs)
About the session

We are looking for people who could visit our offices at the Royal United Hospital in Bath, in September this year.

The session will take up to 1.5 hours and will involve travelling both indoors and outdoors on the hospital site. We would like you to test the product with your wheelchair.

If you are interested in taking part we will be in touch in advance of the session to discuss your needs, including any support you require to attend or take part, and whether or not you would like to bring your child and anyone else along to the session. 

Practicalities of taking part

· We will be following any relevant Covid-secure guidance during the session.

· The hospital site has a disabled toilet, baby changing facilities and a restaurant.

· We can provide an accessible parking space.

· We can reimburse reasonable expenses and as a thank you for taking part we will provide you with a £30 shopping voucher.
The image below shows the wheelchair baby carrier prototype attached to a wheelchair.
2.Based on the information above, please confirm that you would be interested in taking part in prototype testing of the wheelchair baby carrier?

3.If yes, please indicate all of the parts of the week that might be possible for you.
(Please note we are only holding sessions on weekdays. We can offer a choice of days that the session could take place.)
About you

If you are filling this form out on behalf of someone else, please fill out the form with their information.

This information will help us to select people who represent a wide range of experiences and needs. We may not be able to invite everyone who contacts us to take part in this testing.
4.What is your first name?
5.What is your last name?
6.What is your email address?
7.What is your telephone number?
8.Where are you located?
Please provide the first two letters of your postcode:
9.What is your sex?
10.How old are you?
About your Family

We would like to know more about your child(ren) so that we can select people with a range of different family and mobility needs.
11.I would like to use the baby carrier with……
12.How old is the child(ren) that you care for? (please tick all that apply)

The baby carrier is suitable for children from birth to 3 years old (or up to 13kg).

We would still like to hear from you even if your child(ren) is older than 3 years old. 

13.If you have child(ren) who are new-born, up to 3 years old, please tell us their age, weight and length/height.

Please note that the baby carrier is only suitable for travelling with one child at a time.

(If you have multiple children who might use the wheelchair baby carrier, please list all of their ages, weights and lengths/heights below.)

Medical Information

To manage the testing safely we need to understand your medical information as well as how this affects your ability to transfer, sit and mobilise. We also need information about how you would manage (if required to do so) the fitting of the product to your wheelchair and simulate placing your baby in the seat. (this is so that we can be prepared for the session by implementing any precautionary measures which may relate to your disability or condition).
14.Diagnosis:
15.Is there anything else that you would like to share about your health that may affect your ability to take part?
Your Wheelchair and Mobility

Please tell us more about your wheelchair, your ability to self-propel and any support you may have when travelling in your wheelchair. This will help us to understand your level of endurance and how you might want to use a product like the wheelchair baby carrier.
16.Please tell us the manufacturer (make) and model of your manual wheelchair.

(if you have more than one wheelchair please indicate the wheelchair you would use with the baby carrier):
17.Who owns this wheelchair?

(please note that some service providers do not allow the fitting of devices to their wheelchairs so we may need to explore this prior to testing the product with you):
18.When you use a manual wheelchair how often do you self-propel?
19.Do you ever use assisted propulsion (such as being pushed by another person or, via a powered attachment such as e-motion)?
20.Do you ever transport your manual wheelchair in your own vehicle?
21.If yes to the previous question, where do you store your manual wheelchair inside your vehicle when travelling? 

(please tick all that apply)
We need to understand what type of support you may require to lift and/or set up parts of the wheelchair baby carrier to ensure the safety and comfort of all people taking part in testing our prototype.

(If you do not currently have any children aged 6 months to 3 years old, please respond based on what you would anticipate doing or what you did in the past when your child(ren) was this age)
22.Can you independently pick your child (or a heavy object) up off the floor when seated in your wheelchair?
23.Who positions your baby or child in a pushchair or car seat? If you do this, please describe how this is done and any difficulties you have doing this.
24.Does your condition or disability affect your hand function?
25.If yes, please describe how your condition or disability affects your hand function:
26.How do you see yourself using a product like this?

Where would you like to go, and how far would you need to travel in your wheelchair to get there?

(please describe one or two examples below)

Consent

The information you provide will be used by Designability to select people with a range of different experiences for this prototype testing. Your contact details will only be used to contact you about this project.

Designability will store and use the information you provide safely in accordance with our privacy notice.

You may withdraw your application at any time without giving a reason, at which point all data you have provided to Designability in this form will be permanently deleted from our records. To withdraw your application please email: wheelchairbabycarrier@designability.org.uk
27.Do you consent for Designability to use the information you have provided in this way?

28.Is there anything you would like to add?
Thank you for completing the application form.

Please press the Submit button below to send us your completed form.