1 | DCSI –Paper Name Here

To record supervised prescriptionsundertaken togain approved prescriber status for an Equipment/Home Modtype.See relevant procedure listed under row 3 below for details.
Prescriber Details
Surname: / Given Name: / Contact Phone Number:
Prescribing ServiceSelect from the following dropdown list Please select Disability Services ASSISTDisability Services C&YSDom CareNovita / Discipline:
Prescribing TeamSelect from the following dropdown lists Please select (Disability Services)ILCCountry South: Murray Bridge/Victor HarbourNorthern: Gawler/BarossaNorthern: Gilles PlainsNorthern: SalisburySouthern: Central AdelaideSouthern: Daw ParkSouthern: Mt BarkerASSIST CentralASSIST North ASSIST South Please select (DomCare)RehabTherapy Solutions NorthTherapy Solutions SouthPalliativeTherapy Solutions Central Please select (Novita)ABIAssistive Technology ServiceNovita-TechPRPRS-NorthRS-SouthCentral Metro ServicesNorthern Metro Services
Equipment/Home Modificationtype
for supervised prescription
(Select Equipment/Home Mod type from dropdown lists) / Equipment A-MAdult Postural ChairBath Supports - ComplexBidetChildrens Bath on Stand (customised)Childrens Bath on Stand (non customised)Children's Posture Chair T2Children's Posture Chair T3Childrens Walker T3Childrens Walker T4Complex BedElectric BedElectric ReclinerHoist - CeilingHoist - MobileHoist - Stand AidM SH C 1M SH C 2M SH C 3M SH C 4MWC 1MWC 2MWC 3MWC 4 / Home Modifications A-HAlter bench height (Kitchen)Alter cupboards to give leg clearance (KitchenAlter sink height (Kitchen)Create doorway/remove section of wallDoorway wideningElectronic door openerFold-down shower seat fixed to wallHand rails for major step modificationsHand rails for ramps over 300mmHand rails for ramps up to 300mm
Equipment N-ZPerson Lifter for CarPressure MattressPressure Reduction OverlayPWC 1PWC 2PWC 3PWC 4Scooter - 3W and 4WSeating T2Seating T3Seating T4SGD T1SGD T2SGD T3SGD T4SGD T5SGD T6Showerhoses (push on)SlingStanding Frame (Child) T3Standing Frame (Child) T4Stroller Type 2Towbar Mounted CarrierWheelchair Lifter (eg Wymo) / Home Modifications I-ZInstall accessible storage shelves (kitchen)Install basin with leg accessInstallation of combi doorInstallation of stepless showerKerbs and kerb rails on ramps up to 300mmKerbs and kerb rails on ramps over 300mmLever taps/ceramic disc tapsMajor ramp 190mm - 300mm heightMajor Ramp 300mm - 1000mmMajor step modifications (total height >300mm)Pull out benchtop (kitchen)Relocation of light switches for access modsRelocation of toilet within bathroomRemoval of bathRemove or resite vanityRemoval of shower screen & replace with curtainResite (only) cooktop, ovenShower hoses - installedSlip resistant floor tiles
Prescription / If prescriber NOTskilled afterrecommended 3 supervised prescriptions, approved prescriber to consult with clinician and supervisor re further supervised prescriptions allowed.
Supervising Approved PrescriberName / Supervising Approved PrescriberSignature / Prescribing therapist
Signature / DateAx Completed / Comments (e.g. client name, equipment details) / Skilled
?
1 / Y / N YESNO
2 / Y / N YESNO
3 / Y / N YESNO
If still not skilled; discuss feedback, report & possibly training, see “Achieving Approved Prescriber Status” or “Achieving Approved Prescriber Status for Home Modifications”
4 / Y / N YESNO
5 / Y / N YESNO
I, / (supervising approved prescriber), confirm the prescribing therapist hasdemonstrated skilledprescription as above
and can become an approved prescriber for the specified Equipment/Home Modification type. / Signature: / Date:
Other Comments:
Clinical/Profession Leader/Delegate Name: / Clinical/Profession Leader/Delegate Signature: / Date:

Once form completed, please forward to Equipment Program Training Coordinator, Domiciliary Equipment Service Fax: 1300 295 673 or

1 | DCSI –Paper Name Here