Appendix H
OAHM Program Documentation of Work Completed Form
Older Adults Home Modification Program
Documentation of Home Modification Work1
Study ID: |
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Today’s Date (mm/dd/yyyy) |
Form Completed By: |
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Site ID |
Client ID |
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Name |
Job Title |
Organization |
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(dropdown menu: OT, OTA, CAPS, other [Specify]) |
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OMB Control No. 2528-XXXX, expiration date XX/XX/2024. This form is designed to provide HUD with information about how effective its Older Adults Home Modification Grant Program is. Your participation in the Evaluation as a grantee is mandatory as a condition of the grant. The Public reporting burden for your collection of information is estimated to be 30 minutes per response. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
Instructions: The purpose of this form is to document home modification tasks and costs. Do not include costs related to assessing the home to determine home modifications needed (e.g., OT-related assessment costs) or costs to administer the OAHM Program (e.g., grantee project management costs). Number home modification tasks, entering one home mod per row. Optional: Upload supporting documentation (e.g., invoices). List any donated materials, with $0 cost.
Home Modification Start Date (mm/dd/yyyy):_______________ Home Modification Work Completion Date: (mm/dd/yyyy):______________
Complete only if additional home modification work was provided after initial work was completed: Additional Home Mod Start Date (mm/dd/yyyy): ________ Additional Home Mod Work Completion Date (mm/dd/yyyy):_________
Was HUD OLHCHH pre-approval obtained for this work? □ Yes □ No
Did you have to temporarily relocate residents during this work? □ Yes (include any associated costs in table below) □ No
Did this work require a HUD environmental review? □ Yes (include any associated costs in table below) □ No
(REDCap: See pages 2-3 for column dropdown lists)
Task # |
Task Specified By: |
Task |
Room |
Program Paying for Task |
Home Modification Materials |
Grantee In-House Labor Costa,b |
Subcontractorb |
Total Cost |
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Type |
Description (optional) |
Unitc |
Quantity |
Cost |
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Type |
Cost |
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a Only include grantee costs associated with completing the listed home modification task. Do not include grantee labor costs associated with managing the OAHM Program.
b For in-house home modification labor costs and subcontractor costs, include overhead/profit in the task cost.
c Unit= unit of measure, e.g., square foot, linear foot, item, etc.
Older Adults Home Modification Program
Documentation of Home Modification Work
REDCap Dropdown Lists:
Task Specified By: OT, OTA, CAPS, RN, other Home Mod Contractor, Social Worker, Other (Specify)
Task Type: Grantees should pick one description per row. For example, they should not enter “repair stairs” and “install railing/banister” in a single row.
Feature or System |
Specify details |
Activity |
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Accessibility item |
□ graded ground ramp □ temporary/modular ramp □ permanent ramp with footings set into ground □ stairlift □ wheelchair platform and lift Specify: |
□ Repair □ Replace □ Install temporary item □ Install permanent item |
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Adaptive equipment |
Specify: |
(no check boxes here) |
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Carpet |
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□ Repair □ Replace □ Remove □ Install |
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Exterior Door (Room=Exterior): |
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□ Adjust door swing □ Install automatic door or door openers □ Install door hinge offset or swing clear door hinges □ Install hands-free door hold open capability □ Replace door lock □ Install magnetic screen door □ Install or adjust height of peephole □ Add security technology to door □ Install secure slide latch or chain □ Repair broken door window pane(s) □ Repair door □ Replace door □ Install new door □ Widen doorway □ Other Specify:___________________ |
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Interior Door |
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□ Adjust door swing □ Install automatic door or door openers □ Install door hinge offset or swing clear door hinges □ Install hands-free door hold open capability □ Replace door lock □ Repair door □ Replace door □ Install new door □ Widen doorway □ Other Specify:___________________ |
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Electrical features |
Specify: |
□ Install light switches/electrical outlets □ Replace light switches/electrical outlets □ Move light switches/electrical outlets □ Install GFCI outlets in wet areas □ Repair light switches/electrical outlets □ Rewire home □ Install new electrical service □ Replace/move electrical panels □ Other Specify:___________________ |
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Floors |
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□ Repair □ Replace □ Install new floor □ Install/replace carpet □ Other Specify:___________________ |
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Grab bars |
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□ Repair □ Replace □ Install |
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Gutters/downspouts (Room=Exterior) |
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□ Repair □ Replace □ Install |
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Hallways |
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□ Widen hallway |
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Door Handles |
Specify: |
□ Repair □ Replace □ Install |
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Faucet Handles |
Specify: |
□ Repair □ Replace |
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Handrails, railings, stair banisters |
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□ Repair □ Replace □ Install |
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Home Safety Device |
Specify: |
□ Repair □ Replace □ Install □ Install fire suppression system |
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HUD Environmental Review |
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(no check boxes here) |
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HVAC/plumbing system |
Specify: |
□ Repair □ Replace thermostat □ Install □ Replace major feature |
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Kitchen |
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□ Repair/replace existing cabinetry □ Replace cabinet hardware □ Install/replace fire extinguisher □ Install automatic stove shutoff device □ Remodel kitchen □ Install lower work surface that can be used while seated □ Lower cabinets □ Repair/replace countertop(s) □ Appliance repair Specify appliance:__________ □ Appliance replacement Specify appliance:___________ □ Other Specify:___________________ |
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Laundry |
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□ Move washer and/or dryer □ Replace washer and/or dryer □ Other Specify:___________________ |
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Lighting |
Specify: |
□ Repair □ Replace □ Remove □ Install |
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Pathways/walkways and driveways (Room =Site) |
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□ Repair □ Replace □ Place anti-slip tape, colored tape, or paint on surfaces □ install pathway lighting |
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Porch (not including railings) (Room=Exterior) |
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□ Repair □ Replace □ Install |
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Pressure-mounted pole (“superpole”) |
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□ Repair □ Replace □ Install |
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Roof (Room=Exterior) |
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□ Repair □ Replace |
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Shelving or cabinetry |
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□ Repair □ Replace □ Move □ Install |
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Bathroom (Room=Bathroom) |
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□ Add nonskid strips to tub/shower floor □ Install handheld or adjustable showerhead □ Install tub cuts to enable easy entry/conversion to shower □ Install curved shower curtain rod □ install pedestal or wall-hung sink for wheelchair accessibility □ Insulate or cushion exposed pipes beneath sink □ Install/replace/adjust bathroom mirror, toilet paper holder, and other permanent accessories □ Replace cabinet hardware □ Repair wall tile □ Secure rugs with carpet mesh or double-sided rug tape □ Install toilet riser with handles □ Install toilet safety frame or rails □ Toilet Repair □ Toilet Replace □ Remodel bathroom □ Install new wall tile □ Install walk-in tub or shower □ Other Specify:___________________ |
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Slippery surfaces |
Specify: |
□ Power-wash □ Non-skid strips |
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Stairs/steps-Exterior (Room=Exterior) |
Specify: |
□ Repair □ Replace □ Place anti-slip tape, colored tape, or paint on surfaces |
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Stairs/steps-Interior |
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□ Repair □ Replace □ Maintain chair lift/stair climber □ Place anti-slip tape, colored tape, or paint on surfaces □ remove carpet |
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Temporary Resident Relocation |
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(no check boxes here) |
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Thresholds/Room Transitions |
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□ Repair □ Replace □ Remove |
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Walls and ceilings |
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□ Repair □ Install new |
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Windows (Room≠Exterior) |
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□ Repair □ Replace |
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Other |
(Specify): |
□ Repair □ Replace □ Remove □ Move □ Install □ Complete room remodel |
Location:
Room |
Specify Details (e.g., location in home) |
Site (for tasks conducted outdoors on client’s property [e.g., client’s driveway, cient’s deck, client’s yard]) |
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Exterior (for tasks conducted on home exterior [including entrance doors, porches, balconies, etc.]) |
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Hallway |
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Living Room/Family Room |
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Foyer |
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Bathroom |
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Laundry |
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Kitchen |
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Dining Room |
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Bedroom |
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Other |
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Program Paying for Task: OAHM Program, Other in-house program (specify [e.g., weatherization, accessibility, CDBG, etc.), referral organization (Specify Org.), Other (Specify)
Home Modification Materials Unit: square foot, linear foot, item, inches, liters, square yard, feet, meters, cm, other (specify)
Subcontractor Type: General, Electrician, Plumber, Painter, Carpenter, HVAC, Other (specify)
1 Code for this document: Black font=Question asked of the grantee; Blue italics = Instruction for the grantee; yellow highlighted italics: Instruction for Excel programmer.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Noreen Beatley |
File Modified | 0000-00-00 |
File Created | 2022-07-21 |