Use when a need for home modification(s) is identified, additional diagrams may be required.
Complete form and email to or fax to 1300 295 839
Participant NDIA ID No.: / Date:
ParticipantSurname: / Given Name:
Phone: / DOB: / Client weight:
Usual address: Suburb: Post Code:
Address to be modified: Suburb: Post Code:
Prescriber Name: / Discipline: / NDIA Provider No.
Agency: / Email: / Phone / Fax:
Contact for modification(s): / Phone:
Safety precautions:
Additional Instructions:
Discharge from hospital dependent on Home Mods completion? Y / N YESNO Completion date if required
Installation timeframe: Low Med High Urgent (exceptional circumstances only)

Please Note:The above home modifications will only be installed subject to approval from National Disability Insurance Agency; further approval may be required for major modifications

The following modifications have been clinically recommended:

1.

2.

3.

4.

5.

I, , agree for the recommended home modifications specified above (subject to approval) to be installed by Domiciliary Equipment Service. I have been involved in the prescription of the home modifications and believe to the best of my knowledge they will meet my needs.

Participant/ GuardianSignature:Date:

I,, the owner of this dwelling, give permission for the modifications listed above to be installed by DCSI (subject toapproval). I have received, read, understood and accept the Terms and Conditions of Installation of Home Modifications.

Owner of property Signature: Date:

Note: Prescription will not be processed without all signatures

Internal Use only:
Portal Checked Y/N / Name: signed: / Date:

Those listed with (*) require a diagram

Grabrails and Handrails
300mm grab rail* No. required:
450mm grab rail* No. required:
600mm grab rail* No. required:
750mm grab rail* No. required: / 900mm grab rail* No. required:
1200mm grab rail* No. required:
Other*: mm No. required:
Custom hand rail (banister) rail* No. required:
Ramps and Steps
Threshold Ramp* No. required:
Step Ramp*No. required:
Long Ramp (inc. handrails / kerbing)*No. required:
Platform Step*No. required:
Half Step (inc handrails)*No. required: / Portable Ramps
700 mm (no edge) 875 mm (no edge)
1200mm 1350mm 1650mm 2000mm
with edge without edge
Specialised Taps and Water Temperature Control
Specialised Taps (no plumber)
Specialised Taps (requires plumber)
Water temperature control valve / Details (types, where):
Bathroom Modifications
Fixed Shower Hose
Slip-resistant tile coatingArea Size:xm
Slip resistant floor tiles*
Fold-down shower seat (fixed to wall)*
Removal of shower screen and replace with curtain rail*
Removal of shower hob*
Installation of stepless shower*
Specialised taps (plumber required)* / Remove or resite vanity*
Install basin with leg access*
Relocation of toilet within bathroom*
Remove/relocate bath or install hobless shower and/or widen/relocate doorway*
Combine bathroom/toilet/laundry, to include remove/relocate bath or install hobless shower and/or widen/relocate*
Other*:
Kitchen Modifications (No Structural Work)
Alter bench height*
Alter cupboards to give leg clearance*
Pull-out bench top*
Specialised taps (plumber required)* / Resite cook top / oven*
Install accessible storage shelves*
Other*
Access
Doorway widening (inc relocation of light switches)*
Re-swing doors*
Remove door jambs*
Remove door*
Lever door handles No. required:
Magnetic door holdersNo. required:
Replace swinging door with sliding door* / Create doorway (inc relocation of light switches)*
Relocation of light switches*
Installation of combi door*
Electronic door opener*
Door modification / bi-fold doors*
Wall and door protector plates*
Other*:
Wall construction: Solid Brick Timber Frame Steel Frame Joint site visit required with prescriber / installer

Prescriber checklist:All signatures obtained Diagrams attached No.: Photos attached No.:

Prescriber name: Signature:

S

Check for latest e-version, printed copies may be out of date: Released: 18/7/2013 Page 1 of 2