Wheelchair-to-Car Transfer Checklist
Use this checklist to ensure all safety and procedural steps are followed during a wheelchair-to-car transfer.
Name of Person Completing Checklist
*
First Name
Last Name
Role/Relationship to Person Being Transferred
*
Please Select
Caregiver
Healthcare Professional
Family Member
Self
Other
Date and Time of Transfer
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Name of Person Being Transferred
*
First Name
Last Name
Type of Vehicle
*
Please Select
Sedan
SUV
Van
Truck
Other
Type of Wheelchair
*
Please Select
Manual Wheelchair
Power Wheelchair
Transport Chair
Other
Pre-Transfer Safety Checks
*
Wheelchair brakes applied
Footrests removed or flipped up
Seatbelt unfastened (if present)
Car seat positioned appropriately
Other
Transfer Process Steps
*
Rows
Completed
Not Applicable
Position wheelchair close to car seat
1
2
Lock wheelchair brakes
3
4
Assist individual to edge of wheelchair seat
5
6
Provide support for standing (if applicable)
7
8
Pivot and guide to car seat
9
10
Ensure safe seating and comfort in car
11
12
Transfer wheelchair to car/storage
13
14
Assistive Devices or Equipment Used (if any)
Transfer board
Gait belt
Slide sheet
None
Other
Were there any difficulties or safety concerns during the transfer?
*
No
Yes (please describe below)
If yes, please describe any difficulties or safety concerns encountered.
Additional Comments or Observations
Submit Checklist
Should be Empty: