Operation Independence, LLC – Spinal Injury Assessment

First Name

Last Name

Room #

Case Manager

What type of services did the patient receive prior to hospitalization?

Home Health Aide
Homemaker
PT
OT
Speech

Assessment done by

Upload Photo(s) of Entry

What Type of Home

If Single family

Bedroom is on

What floor is apartment on?

If there are stairs, how many are there?

Is there a railing on stairs?

Is a hand rail needed?

Is there an elevator?

Apartment is Handicapped Accessible

Which entrance is used as primary?

What type of surface leads to the entrance?

Is there a porch or vestibule at primary entrance?

Preferred accessible Entry point

How many stairs at point of entry?

Riser Height

Tread Depth?

Stair Abnormalities?

Railing

Does the landing have a railing?

If yes, is the railing?

What is the size of the landing?

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List

Describe width and shape of hallway

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List rooms off of hallway

List rooms most frequently used and note door widths

What chair do you sit in most frequently?

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Describeflooring throughout areas of accessible need

Bedroom door width?

Bedroom Door Threshold?

Type

Height of bed

Are both sides of bed accessible?

Approximate distance to bathroom

Upload picture(s) of bedroom

Width of kitchen doorway

Is there a threshold to Kitchen?

Describe kitchen layout

Distance from meal prep to table

Type of chairs at Kitchen/dining table

Height from floor to bottom of table

Upload Picture(s) of Kitchen

Width of bathroom door?

Is there a threhold?

Door Swing

Type of floor

Size of toilet Height, Depth, Width

Grab bars near toilet

Describe sink and cabinet - include dimensions and type of faucet

Describe current bathing area - include height/width/depth and plumbing

What is the shower opening width?

Describe shower door/curtain in detail include door swing

Height of shower threshold

describe grab bar qty/placement

Upload PDF drawing of bathroom layout

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