Wheelchair-to-Toilet Transfer Assessment Checklist Form
Use this checklist to evaluate wheelchair-to-toilet transfer safety, assistance needs, equipment, and environmental considerations.
Assessment Basics
Assessed Person Name or ID
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name and Role
*
Assessment Location
*
Transfer Ability and Safety Checklist
Transfer Independence Level
*
Independent
Needs Verbal Cueing
Needs Partial Physical Assist
Needs Full Assist
Overall Transfer Safety Risk
*
1
2
3
4
5
Safety Factors Checklist
*
Rows
Yes
No
Needs Assistance
Not Assessed
Balance
1
2
3
4
Upper Body Strength
5
6
7
8
Standing Tolerance
9
10
11
12
Toileting Access
13
14
15
16
Wheelchair Positioning
17
18
19
20
Grab Bar Access
21
22
23
24
Ability to Follow Instructions
25
26
27
28
Assistance, Equipment, and Environment
Type of Assistance Required
*
No assistance
One-person assist
Two-person assist
Mechanical lift
Other
Mobility Aids / Equipment Used or Needed
Gait belt
Transfer board
Commode
Grab bars
Raised toilet seat
Wheelchair lock check
Other
Environmental Barriers / Precautions
Narrow space
Wet floor risk
Toilet height issue
Clothing management difficulty
Need for repositioning
Poor lighting
Other
Submit Assessment
Should be Empty: