Home Modification Recommendation Form

Records recommended home modifications such as grab bars, ramps, and bathroom changes, along with the rationale, urgency, and coordination details for caregivers and contractors.

Recommendation Summary

• Recommendation Title
  Short title for the recommended home modification.
• Type of Modification
  Select the primary modification being recommended.
• Rationale for Recommendation
  Describe the safety, accessibility, or mobility concern that supports this recommendation.
• Urgency Level
  Indicate how soon the modification should be addressed.

Home Area and Modification Details

• Area of the Home
  Select all areas where the recommendation applies.
• Specific Location Notes
  Optional details such as 'left side of tub' or 'front entry step'.
• Grab Bar Details
  Shown when grab bar installation is selected. Include preferred placement, quantity, or support needs.
• Ramp Details
  Shown when ramp installation is selected. Include entry point, slope concerns, or landing needs.
• Bathroom Modification Details
  Shown when bathroom accessibility modification is selected. Include tub-to-shower conversion, raised toilet, transfer space, or other needs.

Functional Impact and Safety

• Mobility or Access Limitations
  Select the limitations relevant to this recommendation.
• Safety Concerns
  Describe any observed hazards or risks that the modification would help reduce.
• Expected Duration of Need
  Indicate whether the modification is expected to be temporary or long-term.
• Supporting Documentation
  Optional supporting notes, assessment, or photo documentation. Do not include unnecessary PII.

Caregiver and Contractor Coordination

• Caregiver Name
  Optional name of the caregiver coordinating the request.
• Caregiver Email
  Optional email for coordination and follow-up.
• Contractor Follow-Up Needed?
  Select yes if the recommendation should be shared with a contractor or vendor.
• Consent to Share Recommendation
  Consent to share the recommendation and any provided contact details with a contractor or vendor for coordination.
• Preferred Contact Method
  How the coordinator should contact the caregiver or requester if follow-up is needed.

Review and Submission

• Additional Notes
  Optional details that would help with planning, scheduling, or installation.
• Your Name
  Optional name of the person submitting this recommendation.
• Your Role
  Optional role such as caregiver, clinician, case manager, or contractor liaison.