This form is for use by Framework Occupational Therapists providing home modifications assessment services to and WorkSafe Victoria (WorkSafe). The information in this form is for use by the organisation which has requested it and will not otherwise be exchanged with any other party, except in accordance with law. Please see section 13 of this form for further information. IMPORTANT Approval from the /WorkSafe Agent must be obtained prior to completing a home modifications assessment Please type or use block letters and ensure that all sections are complete All incomplete forms will be returned. Please provide reasons if you are unable to complete a section. 1. Client/worker current details Client/worker name Type of claim WorkSafe Agent Address of property to be modified Claim number Telephone number/email/fax Date of birth Date of injury/accident / / / / Postcode Employer Employer telephone number Current occupation Date of assessment Date report submitted Pre-injury occupation / / / / 1a. If currently an inpatient, please outline which hospital, the current discharge plan and the anticipated discharge date Comments in this section should relate to decisions made about where and with whom the client/worker will live after discharge from hospital, and how long it is expected they will reside in the house which is being assessed for modifications. Detail the client/worker’s anticipated household/social situation. Not applicable 2. Scope of assessment as per referral 3. Property details 3a. Home ownership Please select the ownership status of the property being assessed Client/worker owned Co-owned Private rental Public rental Family owned Other, e.g. Senior Masters Additional comments Where ownership is other than the client/worker, provide more details, e.g. name of real estate agency and contact number Has the property had previous modifications funded by the or WorkSafe? Yes No If ‘yes’, please outline previous modifications completed
General safety Personal ADL Current status Including impact of physical, cognitive or behavioural issues on client/worker’s independence Expected future level of independence Toileting Dressing Showering/bathing Grooming Other Domestic ADL Current status Expected future optimum level Who completed this task prior to the accident? Meal preparation Cleaning Laundry Other Community Activities/ Access Current status Expected future level of independence Recreation and leisure Driving and/or transportation in vehicle/cars Work and study issues 7. Goals of the proposed home modifications In nominating goals, consider the area of the home and what the recommended specifications for home modifications will achieve If the client has an Independence Plan, please align the goals of your proposed home modifications to the client’s goal(s) where feasible. Area of the Home Goal Functional Skill Example: Bathroom Example: Gina will be able to shower independently and safely after bathroom modifications Example: Mobility, general safety 8. Recommendations You should detail the client/worker’s existing home environment and provide clinical justification for any and all home modification recommendation(s). Recommended specifications for access must be consistent with Australian Standards 1428.1 unless specifically referenced as an ‘exception’.