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Home Modification Resource Coalition Project — Resources

READ Intake form

READ Procedures

READ Home modification contractors

Intake form

Council for Disability Rights
Home Modification Resource Collaboration
Client Intake Application

Initial Contact Date:_____ Application Date:_____ Referral Source:_________________

Name:  First_______________ Middle Initial____ Last_________________________

Address:__________________________ City__________ State_____ Zip____________

Phone/TTY:______________ Cell:________________ Email:_______________________

Social Security Number:________________ Date of Birth:____________ Age:_____

Marital Status __________

Currently Employed: Y  0  N 0  Part-time 0 Full-time 0 

If yes, how long have you been employed?____________________________________

Employer/Supervisor Name and Phone Number___________________________________

If no, are you seeking employment or training for future employment?_______________

Please explain how Home Modifications will enable you to return to work or continue working?

Education Level______________________________________________________________

Income Source:____________Amount: $____  # of People in Household:___________

Disability Type __________________ Preferred Language________________________

Do you rent the property to be modified?  Y  0  N 0  If yes, Rent $______Lease exp.____
Landlord approves modifications? 0 Yes  0 No   Name/Phone____________________
Do you own the property to be modified?  Y 0 N 0 If yes, Mortgage $______________


**The following pages to be filled out if/when second visit is scheduled.

Vocational Information

DRS Active case 0 yes 0 no Date opened _______Referral 0 yes 0 no Date______
DRS Counselor__________________________DRS Office___________________________

Income Source

Wages $______ SSDI   $______  SSI   $_____ Public Aid $_____________________
Link Card_____  Pension______ Other  _________   Total: $___________________  

Social Network/Community Connections

Are currently receiving services from other agencies? 0 Yes   0 No
Agency Name ________________________________________________________________
Services received:__________________________________________________________
Contact Person __________________________________Phone # ___________________

Membership in Club or Organization 0 Yes  0 No 
Contact Person __________________________________Phone # ___________________

Are you a Veteran? 0 Yes 0 No  Branch of Service _______________Dates ______

Faith Based Affiliation (optional) _________________________________________
Contact Person __________________________________Phone # ___________________

Healthcare Benefits

0 Private Insurance__________________________________
0 Medicaid (Spend down?) $ _____ 0 Medicare  0 VA ____ 0 Other______________

Medical Information
Disability Type ____________________________________________________________
Functional Limitations______________________________________________________
Adaptive Equipment used_____________________________________________________

Are you currently receiving PT services? 0 Yes 0 No    How often? __________
Provider:__________________________________  Phone # _______________________

Are you currently receiving OT services? 0 Yes 0 No    How often?___________
Provider: :___________________________________Phone # ______________________

Are you currently receiving DRS Home Services? 0 Yes  0 No  0 PA 0 Homemaker 
# of hours of assistance per week? _________________________________________ 
Agency___________________________ Phone# ___________________________________
Service Cost Maximum $ ____________DON Score _______________________________
Unmet Needs ________________________________________________________________

Terms of Agreement

Please initial boxes as appropriate:

Statement of Authenticity

I certify that the information provided is true and correct to the best of my knowledge. 
I request these accessibility modifications with the intent to enter the workforce or maintain employment.

Waiver of Liability

I understand this project will be completed as a good faith effort. 
I do not hold the Council for Disability Rights, its staff, volunteers or third parties responsible 
for problems associated with goods or services provided and/or removal or maintenance of any Home
Modification that is completed through this program. 
Permission for Publicity

I hereby grant permission to photograph or videotape myself and/or my property to be used to promote
the mission of the Council for Disability Rights.
Client Signature_______________________________________ Date______________

Staff Signature_______________________________________ Date_______________

For Office Use Only:

Application accepted: 0 yes 0 no Date: ___________________________________
Onsite assessment scheduled 0 yes  0 no Appt Date _______Time_____________
CDR services provided_____________________________________________________
Other agency services provided____________________________________________
Customer Service Survey Completed_________________________________________
Follow-up visit scheduled_________________________________________________
Additional Notes:_________________________________________________________


Referral and Application

  • An Individual with a disability may be considered for services through a referral from another agency or service provider, or s/he may make a self-referral by contacting the CDR office.
  • If after an initial screening, s/he meets the criteria for the HMRC project, s/he will be asked to complete an application. Upon receipt of the application, an appointment will be scheduled for a face to face interview.
  • An applicant not selected to receive home modifications will be provided with information and assistance to link him/her with other appropriate community resources. Information and referral activities will be carefully recorded and reported to the Department of Labor to document need for such services.
  • If CDR believes the individual is a potential candidate, an on-site assessment will be scheduled with the Project Occupational Therapist to evaluate specific needs for modifications and adaptive equipment.
  • As needed, appropriate referrals will be made in order to coordinate services of applicants.
Review Committee

It is anticipated that there will be many more requests for assistance than Project resources can accommodate. Therefore, a committee has been established to make a final determination regarding which applicants will be chosen to receive services. A number of factors will be considered by the members of the committee including:
  • Impact of home accessibility modifications on the person's ability to achieve or maintain employment.
  • Feasibility of modifications (i.e., whether the needed changes would be too costly, and whether they can reasonably be made based on structure and space at building site).
  • Availability of other resources for the applicant
Client Selection

Clients who will receive products and services must meet certain eligibility requirements including, but not limited to:
  • The presence of a physical (mobility or sensory) disability that interferes with the individual's ability to obtain and maintain employment.
  • Actively pursuing an employment goal or currently employed.
  • With the provision of service the individual will be better able to obtain and maintain employment.
  • Preferably have an open DRS case. Recipients of SSDI/SSI will be given preference.
  • Resident of Cook County.
Cost Sharing or Financial Participation
  • Each client selected will be asked to participate in the expenses of the modifications provided. This contribution can be in the form of a monetary donation, recruitment of volunteer labor, or the acquisition of needed materials.
  • A sliding scale has been designed to determine the minimum amount of contribution expected based on an individual's income. (See DHS:Chapter IV) Section 562.APPENDIX A Standard Budget Allowances/2003) If the client's income is above the standard allowance, s/he will be asked to pay 50% of the exceeded amount.
  • Clients whose only source of income is Social Security will be exempt from mandatory financial participation.
Contractor Selection Submission of bids or proposals:
  • If a project expense exceeds $500, three quotes must be obtained by CDR from approved contractors.
  • Bids will be reviewed by CDR staff and staff of UIC and a contractor will be selected. The decision can be based on suitability of the proposal to meet client needs and not merely on monetary factors. A contractor will not be chosen for a job simply because s/he submitted the lowest cost bid. The work proposed should be cost-effective, but it also must be appropriate to meet the particular client's need for improved safety and independence.
Project Implementation

When a client has been selected to receive needed modifications and/or adaptive equipment and a comprehensive evaluation has been conducted to determine the specifics of the project, a number of steps will be taken to carry out the needed work:
  • CDR staff will ensure that all needed documents have been completed (e.g., liability waivers, landlord approvals, permits, etc).
  • CDR staff will schedule the chosen contractor who has agreed to provide the modifications according to an approved plan at the agreed upon cost.
  • If another organization will share the responsibility for services to a particular client, CDR staff will secure the appropriate agency partnership agreements and follow up to ensure all parties have fulfilled their portion of the project.
  • If a vendor requests assistance in acquiring materials or if donated items will be used, CDR staff will obtain supplies and equipment as needed.
  • CDR and/or clients will recruit laborers as needed if volunteers are appropriate for a specific project.
Follow-up and Evaluation
  • After completion of project, a follow-up inspection will be conducted by a staff member of UIC as a quality assurance review.
  • After completion of project a client satisfaction survey will be completed by client.
  • All outstanding invoices will be paid.
  • Necessary reports will be submitted to the Department of Labor and other Funders/Donors involved in project.
Appeal Process
  • Individuals who disagree with CDR's decision regarding services through the HMRC Project have the right to appeal.
  • Requests for reconsideration must be submitted in writing within 10 days of being informed of the decision. This letter should state reasons why the individual disagrees with CDR's position.
  • CDR staff and members of the Project Coalition will review this letter requesting reconsideration. The applicant will be informed of the appeal board's determination within two weeks of receiving the appeal.

Home Modification Contractors This list of vendors is provided to assist you, our clients, in meeting your needs for assistive devices. We do not endorse any particular vendor. We do not benefit from the sale of any equipment. We cannot be held responsible or liable for any damage, loss or injury arising out of your access or inability to access these vendors; your purchase or use of products; or the quality or content of products offered. The information provided is accurate and complete as of August 7, 2004.

Accessible Living, Ltd. — P.O. Box 447, Yorkville, IL 60560
(630) 553-6607
Exterior modifications, minor interior modifications and lifts

Access Specialists, Inc. — 506 S. Westgate Drive, Addison, IL 60101
(630) 628-6909 / fax (630) 628-7008
Exterior and interior modifications, ramps and lifts

Allen Realty and Builders — 187 N. Marion, Oak Park, IL 60304
(708) 383-8080

DME Access — 1717 Industrial Drive, Montgomery, IL 60538
(630) 892-7400 / fax (630) 892-7401
Lifts, residential elevators and ramps

Extended Home Living Services — 5230 Capitol Drive, Wheeling, IL 60090
(847) 215-9490 / fax (847) 215-9632
Exterior and interior modifications, ramps and lifts

Lang Home Medical Equipment — 1552 Barclay, Buffalo Grove, IL 60089
(847) 537-2257
Exterior and interior modifications, ramps and lifts

Midwest Accessibility & Design — 835 Cedar Avenue, Elgin, IL 60120
(847) 913-0225
Exterior modifications and lifts

Mobility Systems Inc. — 7703 West 99th Street, Hickory Hills, IL 60457
(708) 599-3500
Exterior and interior modifications and lifts

Steele Home Health Care Center — 2727 Washington Street, Waukegan, IL 60085
(847) 360-4378
Exterior modifications and lifts

World Access — 3 South 604 River Road, Warrenville, IL 60555
(630) 393-7994
Platform lifts and canopies

Council for Disability Rights

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