Completing the Level of Mobility Checklist

For Passengers

To receive appropriate assistance at the airport and on board the aircraft, please inform our staff at the ANA Disability
Desk about the type of assistance you need by filling in the Level of Mobility Checklist on the next page, including
details.
Providing us with this information in advance will help us to provide seamless assistance on the day of your flight.

【Passengers' Individual Needs】
During take-off and landing, support belts and assist seats are available for passengers having difficulty
maintaining an upright seating position in their chair with their seatbelts fastened. Please contact the ANA
Disability Desk.

Wheelchair Check-in
Please let us know the type of wheelchair (manual or electric-powered), whether it is foldable or not, and the size of
the wheelchair you are checking in.
Depending on the size of the aircraft's cargo hold, it may not be possible to load your wheelchair.
If your wheelchair can be reclined, please provide its measurements of being reclined as shown in the image below.

【Electric-powered Wheelchairs】
If you check in an electric-powered wheelchair, the battery will be removed and isolated at the check-in counter on theday of departure. Please inform our staff on how to remove and isolate the battery, or provide the instruction manual.
Please check with your wheelchair manufacturer if you are not sure what kind of battery your wheelchair uses.

【Wheelchair Check-in/Pick-up Locations】
Wheelchairs brought with you can be checked in at a check-in counter and picked up in the arrival lobby. Upon
your request, you can take your wheelchair as far as your boarding gate when checking in your wheelchair andreceive your wheelchair near the cabin door upon arrival. Due to weather and airport facility-related conditions, wemay be unable to accommodate your requests.

【Escorts】
Please be aware that airport staff and cabin crews will not be able to assist with having meals or using the lavatory.
Passengers are asked to travel with an escort when needing above assistance.

【Other】
On the day of departure, personnel may check the size of your wheelchair and its battery specifications at theairport counter. Thank you for your understanding and cooperation.

Level of Mobility Checklist

Full Name of Person Sending FormContact Phone Number

ANA Disability Desk
FAX No. (For residents in Japan) :0120-029-366 (toll-free) / 03-6741-8710*Once your FAX has been received, we will call you to confirm.

Please complete the following fields and place a checkmark in the applicable boxes.
NameAge＜I�nerary / Flight Info＞
Date:
Flight No:（） （（） （（） （（） （Contact info.

From - To:－－－－）（）（）（）（））））

Reservation No/ConfirmationNo:（（（（））））

1. In order to accommodate your needs please let us know your walking condi�on.
□ Able to climb up/down steps but having difficulty walking long distance (need wheelchair use at the airport).
□ Have difficulty in climbing up/down steps but am able to walk from the cabin door to the seat (need wheelchair use to the cabin door).
□ Have difficulty walking without any assistance (require assistance to be seated in a cabin seat from the wheelchair).

2. Please check the box if any of the following apply to you.
□ Unable to maintain an upright seated position with seat belt fastened (during take-off and landing).
3. Please let us know your about wheelchair.
1) Do you have your wheelchair?
□ No, I don't.
2) If yes, what type of your wheelchair is?

□ Yes, I would like to check-in my wheelchair.
□ Electric/Battery-powered□ Manual□(Please select the battery type from the below.)3) Battery type
Other dry-cell battery

Lithium-ion battery

Main unit battery

Wh

Spare battery

Wh

Spare battery

piecesSpare battery

Non-spillable battery

Spillable battery

Top covered, no electrolyte injection port

4) Is the main unit battery removable?
5) Is the wheelchair foldable?

Has electrolyte injection port

No □No □YesYes

6) Size and weight*Please inform our staff about the size of the wheelchair you are checking in.

Depthcm× Widthcm × Height□ Check-in counter

7) Check-in location
4. Do you have any escort to travel with you?
□ No, I travel by myself.
□ Yes.

piecesNamecmkg

Weight□ Boarding gate

AgeReservation No. (Confirmation No.)

5. Other no�ce, Special instruc�on/Precau�on if applicable
ADD01-010-240401