Effective Date: 
4/2004

Documents

Instructions

Updated: 4/2004

Purpose

To serve as the primary source document for specifications for minor home modifications purchased by the provider agency for Deaf Blind with Multiple Disabilities (DBMD) individuals.

Procedure

When to Prepare

The provider agency must ensure that this form is completed prior to procuring bids for any single minor home modification costing $1000 or more.

Number of Copies

Complete one original for each minor home modification and a copy for the individual.

Transmittal

The original form is retained by the provider, and a copy is provided to the individual when he signs it.

Form Retention

Retain this form according to the terms in the DBMD Handbook.

Detailed Instructions

Note: If form is not completed, financial error exceptions may result.

SECTION I — HCSS AGENCY

Participant Name — The provider agency enters the participant's name as it appears on page 1 of the participant's Individual Service Plan (ISP) (Form 6500).

Street Address, City, State, ZIP Code — The provider agency enters the individual's full address.

Modifications Needed — The provider agency enters a general statement of the modifications needed.

Specifications Required for the Modification — The person writing the specifications for the minor home modification lists the specifications, citing any applicable local regulations, requirements of the construction, and applicable Texas Accessibility (TAS) standards. This is a detailed description of the construction (Example: Give degree of angle and length of a wheelchair ramp).

Name of Person Writing Specifications — The person enters his or her name.

Signature of Person Writing the Specifications — The person must sign and date the form after he has written the specifications.

SECTION II — LANDLORD

The landlord or owner of the property where the minor home modification is to be made must complete this section before the modification is started. The proposed modification must be described in Section I above.

Name of Landlord — Enter the name of the landlord or owner of the property. Check the appropriate box.

Signature of Landlord — The landlord or owner of the property must sign and date the form.

Note: If the landlord or owner of the property does not approve of the proposed modification, the minor home modification cannot be made on the residence.

SECTION III — PARTICIPANT/RESPONSIBLE PARTY

Section III is to be completed by the individual or the responsible party.

Name of Responsible Party — Enter the name of the responsible party, if the responsible party is signing the form. Check the appropriate box.

Comments — The individual or responsible party should enter any comments, if applicable.

Signature of Responsible Party — The individual or responsible party must sign and date the form.

CORRECTIONS TO ENTRIES

Method of Correction — To correct an error, line through the error, write the correct entry, and initial the correction. Do not use liquid paper/correction fluid. Original entries, corrections, and initials must be legible.

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