NSW Home Modifications and Maintenance Services State Council

OCCUPATIONAL THERAPY WRITTEN SPECIFICATIONSMAJOR BATHROOM MODIFICATIONS

A joint site visit with the builder nominated by the HMMS must be undertaken before finalising the OT diagrammatical and written specifications.

This form is a template for the OT written specifications.

How to complete this form:

1. Retain headings and delete points, as appropriate

2. Client identification (i.e. client name and date of birth) to be included on top right hand corner of page 2 and on all subsequent pages

3. Complete Appendix A- Bath and/or Appendix B-Bidet only if applicable

4. Refer to the NSW HMMS State Council Fact Sheet 17 “Major Home Modifications: Minimum requirements for Occupational Therapy referrals to HMMS”

Date:

Occupational Therapist Client

Name: Full Name:

Organisation: Address:

OT Address:

Phone: Phone:

Email: DOB:

Days Available: Contact Person:

General description of modification required (eg wheelchair accessible bathroom):

WEIGHT OF CLIENT: Please specify if over 100kg .....................................kg

NSW Home Modifications and Maintenance Services State Council 1. Approach and Entry to Bathroom

1.1. Retain existing doorway/Widen existing doorway/Reposition doorway to Wall ................. with distance from corner of Wall ............. to be ................mm (as per diagram....................)

1.2. Specify for widening existing doorway/repositioning doorwayClear door opening to be ...................mmInstall inward opening hinged door/ cavity sliding door/surface mounted sliding door/Smart Door/Bi-fold door/Other (specify)

Latch side on left/right when entering bathroomType of door handle (if applicable) Height of door handle above finished floor surface..................mm

1.3. Re-hinge existing door. Specify

1.4. Provide level access at doorway. If not possible, install a wedge within the door jambs (maximum lip of 25mm) or threshold ramp(as appropriate).Length ....................mm x Width ....................mmWedge or threshold ramp must be clearly visible against adjacent floor surfaces (colour contrast)

1.5. Other

2. Floor Surface

2.1. Floor surface of bathroom and shower recess to be continuous

2.2. Tile bathroom floor with slip resistant tiles - R10 rating (size 100mm x 100mm maximum)

OR

Alternatively specify (eg slip resistant vinyl)

2.3 Other

3. Window

3.1. Retain existing window/ Remove existing window/Install new window/ Other (specify)

3.2. Install new window on Wall Dimensions. Height .................. mm x Width .................mmDistance from corner of Wall .................. to be ...................mm (as per Elevation............... )Height of window sill above finished floor surface of bathroom ....................mmType of window (eg sliding, wind-out style) Specify window operating control (if applicable e.g. extended lever)

3.3. Other (eg safety glass)

NSW Home Modifications and Maintenance Services State Council 4. Shower Recess

4.1. Install a level access shower recess (as per position on diagram ...................)No lip or nosing tile at entry Length .................. mm x Width .................mm Grade to a single floor waste in the shower recess

OR

Grated drainage system

OR

Other (Specify)

4.2 Walls of shower recess to be tiled

OR Other specify (eg slip resistant vinyl)

4.3 Taps to be Capstan/Lever/Flick mixer mounted on wall

Specify Type (if applicable) Standard turn (both taps turn on/off in the same direction) .................. Yes/ No If not standard turn, specify

Length of lever handle (if applicable) ................ mmIndicator on taps (if applicable):Specify colour: Red/Blue Yes/No OR Hot /Cold Yes/ No Position of taps to be either: Horizontally aligned with height above finished floor surface ................mm Centre line of taps/flick mixer to be .....................mm from corner of Walls ..............and ............

OR

Vertically aligned with height of taps ...........mm and .............mm from the finished floor surface of the shower recess.Centre line of taps to be ..................mm from corner of Walls..................and ........................

4.4. Shower Head

Retain/ Install a fixed shower head on wall ................... at a height of .............mm above finished floor surface and .................mm from the corner of walls ................... and .......................

Install a ........... mm length hand held shower hose (HHSH) mounted on Wall ............... as either:

Shower head support grabrail (weight bearing grabrail). Length of grabrail ................mmLowest fixing point above finished floor surface ....................mm.Distance from corner of walls ................... and ................ to be ...................mm

NSW Home Modifications and Maintenance Services State Council OR Hook/peg to be located …...............mm above finished floor surface.Distance from corner of walls …............…and ............... to be...............mm

OR

2nd hook/peg to be located ……...........mm above finished floor surface Distance from corner of walls …….......... and .............. to be................mm. OR

Diverter switch Yes / No

4.5. Install a soap holder wall mounted/recessed on Wall ….............. Height of base of soap holder to be …….........mm above the finished floor surface Distance from corner of walls ……........... and................to be ….......….....mm Specify type (if applicable)

OR

Supply and install soap holder on shower head support grabrail

4.6. Grab rail requirements- See Point 10

4.7. Install a straight /continuous L-shaped/continuous U shaped shower curtain rail at a height to facilitate weighted shower curtain meeting finished floor surface.

Shower curtain to extend across Wall ……............ to cover window (if required) Yes / No

Height of top of shower curtain rail to be ………….........mm above finished floor surface

4.8. Other (e.g. shelf for shampoo container)

5. Bath- See appendix A (if applicable)

6. Toilet:

6.1. Retain existing toilet position/Install new toilet/Install combined toilet bidet (see Appendix B)

6.2. Install a new standard/ disabled toilet pan:Locate toilet cistern on Wall ..................Distance from Wall .................. to centre line of toilet to be 450 mmOther specify (e.g. bariatric requirements)

Distance from back wall to front of toilet pan ................mm Seat height above finished floor surface ................mmFlush control location (specify if not standard).Flush control operation (specify if not standard)

NSW Home Modifications and Maintenance Services State Council 6.3. Grab rail requirements- See Point 10

6.4. Install toilet paper dispenser on Wall….......... /other location (specify) Height above finished floor surface….............mmDistance from corner of back wall......….........mm

6.5. Other

7. Basin/Vanity:

7.1. Retain existing basin or vanity position /Install new basin/Install new vanity

7.2. Install a new wall mounted/pedestal/corner hand basin on Wall ….......

Width of basin to be...................mm and length to be.................mmHeight of rim of basin above finished floor surface to be.............mmCentreline of basin to be ……................mm from corner of Walls…….................. and….…................ Specify type (if applicable) Additional specifications (eg depth of basin)

OR

Install a new vanity on Wall …….. Side of vanity to be ….......mm from corner of Walls…........ and ...……. Dimensions Height …........mm x Width ….........mm x Depth ….........mm Specify type (if applicable eg vanity bench)Self-rimming/semi-recessed/under counter style basin with rim ….......mm above finished floor surfacePosition of drawers (if applicable) Left side/ Right sideHandles type (specify)

7.3. Leg and knee clearance under basin/vanity bench (specify in mm)

7.4. Taps: Capstan/Lever/Flick mixer/SensorSpecify Type (if applicable) Standard turn (both taps turn on and off in the same direction) Yes/ NoIf not standard turn, specify

Length of lever handle (if applicable)……..mm Hot and cold water to be delivered through a central mixing spoutIndicators on taps (if applicable):Specify colour: Red/Blue Yes/No OR Hot /Cold Yes/ No

7.5. Other

8. Storage

8.1. Provide a storage cupboard/mirrored shaving cabinet located on Wall …….Dimensions of cupboard Height ……mm x Width ……...mm x Depth ……...mmHeight of base above finished floor surface to be............mmDistance of centreline from corner of walls……. and...........to be …...….mm

Wall mounted/RecessedHandle type (specify)

NSW Home Modifications and Maintenance Services State Council

8.2. Other (eg shelving, robe hook, wall buddy towel storage)

9. Mirror

9.1. Install mirror on wall ………Dimensions of mirror Height ..........mm x Width ...........mm Height of base above finished floor surface to be............mmDistance of centreline from corner of walls……. and ..........to be …...….mmAdditional specifications (eg centred above basin)

9.2. Other (eg shelf/ angled/ mirror cabinet)

10. Grab rails:

10.1 Grab rails in Shower recess

Install a grabrail(s). Horizontal/Vertical/Other (specify)...................................on wall.............Diameter……....mmLength of straight grab rail….........mmLength of components for combined grab rail(s) – Horizontal…......mm

Vertical…..........mm Height / Lowest fixing point above finished floor surface to be.......... mm To commence............mm from corner of walls......... and............

10.2 Grabrails outside shower recessInstall a …….mm horizontal grab rail, outside the shower recess on wall..................eg for towel/supportDiameter ..........mm

Height of top of grabrail above finished bathroom floor surface …...............….mm To commence.................mm from corner of walls.......... and............

10.3 Grab rails next to toilet Install a grabrail(s), on the left/right hand side when seated on toilet

Horizontal/Vertical/Angled/other (specify)............................................on wall........... Diameter…..…..mm Length of straight grabrail…........mm Length of components for combined grab rail(s) – Horizontal….......mm

Vertical…...........mmAngled…............mm

Height/Lowest fixing point above finished floor surface to be....................mm Height of highest fixing point above finished floor surface (if applicable) to be.............mm

Distance from back wall to be..........mm

10.4 Other grab rails. (Specify as per requirements in 10.3)

11. Water Temperature: Discuss with builder nominated by the HMMS

11.1 Install a thermostatic mixing valve/tempering valve

11.2 Other

12. Lighting/General Power Outlet (GPO)/Fans/Heating:

Discuss with Builder nominated by the HMMS, prior to prescribing electrical items.

NSW Home Modifications and Maintenance Services State Council 12.1 Retain existing light switch/ Install new light switch

12.2 New light switch to be located on wall ……../hallway/other (specify)Height above finished bathroom floor surface ……......mm.

Distance from corner of walls ……...and ......... to be..........mm Type of switch Standard/Rocker action/Toggle switch/ push-pad switch

Additional specifications

12.3 Retain existing GPO/ Remove existing GPO/ Install new GPO

12.4 New GPO to be located (eg within mirrored cabinet, inside vanity) Height above finished floor surface...........mm

Distance from corner of walls...........and ............to be...........mm Other specify (eg shaving outlet)

12.5 Install three-in-one light, heating and exhaust fan Yes / NoAdditional specifications

12.6 Task lighting (if applicable) 12.7 Other

13. Additional Information:

NSW Home Modifications and Maintenance Services State Council

Appendix A - BATH (if applicable):

A.1 Retain existing bath/ Install new bath A.2 Install new bath long side on Wall........... (as per diagram............)

Length ….mm x Width…..mm Height of rim of bath above finished floor surface ….....mmSpecify type (if applicable)

A.3 Install taps on Wall.............. Capstan/Lever/Flick mixer Specify type (if applicable) Standard turn (both taps turn on and off in the same direction) Yes/NoIf not standard turn, specify

Length of lever (if applicable)……...............mm

Indicators on taps:Specify colour: Red/Blue Yes/No OR Hot /Cold Yes/ No

Position of taps: Distance from corner of walls …….. and ..........to be...........mmHeight above rim of bath ….....….mmHot and cold water to be delivered through a central mixing spout.

A.4 Install grabrails. Horizontal/Vertical/Other (specify)...................................on wall.......... (as per elevation............)Diameter……....mmLength of straight grab rail….........mmLength of components for combined grab rail(s) - Horizontal…..........mm

Vertical…..............mm Angled…...............mm

Height /Lowest fixing point above finished floor surface to be..............mm Highest fixing point above finished floor surface to be......................mm (if applicable)Grab rail to commence.................mm from corner of walls............ and ............

A.5 Install a hand held shower hose (HHSH) ..............mm in length, mounted on Wall.…… and to be either:

Shower head support grab rail Length ..……..mmLowest fixing point above finished floor surface …..........mm Distance from corner of walls……. and ......... to be............mm

OR

Hook/peg to be located …….mm above finished floor surface. Distance from corner of walls .......... and.......... to be…….mm.

OR

2nd hook/peg to be located …….mm above finished floor surface.

NSW Home Modifications and Maintenance Services State Council Distance from corner of wall...........and wall............to be.....…….mm.

A.6 Install a soap holder. Wall mounted/recessed on Wall ….......

Height of base of soap holder to be ……...mm above the rim of the bath. Distance from corner of walls …….... and...........to be …….....mm. Specify type (if applicable)

OR

Supply and install soap holder on shower head support grab rail

A.7 Other (e.g. additional grabrails, shower curtain rail)

NSW Home Modifications and Maintenance Services State Council

Appendix B -BIDET (if applicable) Discuss requirements with Builder nominated by HMMS

B.1 Install bidet seat on toilet / or install combined toilet bidet

B.2 Specify for bidet seat on toilet

Specify locationType..................................... (Compatible with toilet) Supplier (if applicable) Weight capacity.............................kgShape of bidet seat - round/elongated/large/other (specify)Height of top of Bidet seat above finished floor surface................mm

Controls:Right/ Left on seat

Or

Wall mounted remote control Yes/NoLocate on wall.............Height above finished floor surface ........mm Distance from back wall.......mmOther (specify)

General Power Outlet (GPO) Utilise existing GPO (within 1500mm of toilet)

OR

Install new GPO on right/ left side of seated client (opposite to water tap preferred, within 1500 mm of toilet)Locate on Wall.............commencing.................mm from corner of walls................and......................Height above finished floor surface to be...........mmDistance from walls........... and...........to be ..........mm

Filter anti bacterial/ standard/ mesh

Specify additional aides for mountings eg.support arms (standard/ splayed, fold down); raised toilet seat

B.3 Specify for separate bidet Specify TypeWeight capacity...............................kgLocate on wall........... (as per diagram.........)Set out from side wall..............to be.............mmSet out from back wall to be.............mmWall/ floor mountedHeight of top of pan above finished floor surface.................mm.

NSW Home Modifications and Maintenance Services State Council Tap system- mixer/ extended lever tap/ flexible hose/other (specify)Flush control location. Specify (if applicable)

B.4. Specify for combined toilet bidet

Locate on wall.............. (as per diagram.........)Specify TypeWeight capacity.............................kgSpecify location Distance from Wall …........to centre line of toilet to be 450 mm/for bariatric client …….....mm (if applicable)Distance from back wall to front of toilet pan..............mm (consider bariatric needs)Height of bidet seat above finished floor surface............mm Flush control location. Specify (if applicable)

B.5 Install toilet paper dispenser on Wall….......

Height above finished floor surface….........mmDistance from corner of walls..............and.............to be .............mm

B.6 Install a grab rail (s) Horizontal/Vertical/Other (specify).............................on wall.......................... (as per elevation.................)Diameter….....mmLength of straight grab rail…........mmLength of components for combined grab rail(s) - Horizontal…...................mm

Vertical…......................mmAngled….......................mm

Height / Lowest fixing point to be..............mm above finished floor surfaceHighest fixing point to be............mm above finished floor surface (if applicable)To commence.................mm from corner of walls.............. and ..............

NOTE: If prescribing a bidet seat on toilet, include specifications for grab rails in point 10.

B.7 Other Disclaimer: The recommendations contained in this form are made after consultation with the client and an investigation of the client’s circumstances and needs. Their purpose is to outline steps required to be taken for the benefit of the client, having regard for his or her disabilities. They do not purport to reflect other than limited knowledge on the part of the Occupational Therapist of structural considerations and building codes. Any queries, concerns or alterations considered necessary for compliance with current building regulations must be discussed with the Occupational Therapist before quoting for the cost of the work and before the work proceeds. The Occupational Therapist accepts no responsibility for supervision of the work or for the quality of the workmanship.

NSW Home Modifications and Maintenance Services State Council

NOTE: Attached to these written specifications are: 1. The following diagrammatical specifications (please tick):

NB: All diagrams must be to scale

□ Existing bathroom floor plan (Mandatory)

□ Proposed bathroom floor plan (Mandatory) □ Changes to spaces adjacent to bathroom eg hallway, bedroom, doorways (Mandatory)

Also elevations (full or partial) of any wall that requires modification, as appropriate(please tick)

□ Elevation Wall A

□ Elevation Wall B

□ Elevation Wall C

□ Elevation Wall D

2. Photographs of existing bathroom and other areas relevant to the modification requested, (eg hallway adjacent to bathroom doorway), if available (please tick)

□ Photographs

Forward these completed written specifications to your Level 1 HMMS with the following: 1) CIARR or equivalent information2) OT Report and Checklist for Major Home Modifications and3) Diagrammatical specifications

The level 1 HMMS will forward all documentation to the level 2 HMS.

The OT Report and Checklist for Major Home Modifications is available for download as a word document from State Councils website www.nswhmms.org