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Run: Home Modification Recommendation Form

This Home Modification Recommendation Form captures the specific changes needed at home, why they’re needed, and who should coordinate next. Use it to docume...

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Recommendation Summary

Recommendation Title (required)

Short title for the recommended home modification.

Type of Modification (required)

Select the primary modification being recommended.

Rationale for Recommendation (required)

Describe the safety, accessibility, or mobility concern that supports this recommendation.

Urgency Level (required)

Indicate how soon the modification should be addressed.

Home Area and Modification Details

Area of the Home (required)

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 (required)

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? (required)

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.

Yes No N/A

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.

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Email (required)

Your name (optional)

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