Home Modification Directory form - homemods.org / NRCSHHM

Name

Title

Name of agency or parent company

Name of home modification program/Resource *

Phone No. *
(Format xxx-xxx-xxxx)

Email *

Website *

Address *

The following questions pertain to the home modification program/resource only:

Number of paid staff

Estimated Number of persons served per year

Primary target population

Date established

SERVICES PROVIDED (SELECT ALL THAT APPLY)
Minor home modifications (e.g., grab bars, raised toilet seats, handheld showers, handrails, lever door handles)Major home modifications (e.g., remodel bathrooms, adjust counter/cabinet heights, ramps, elevator/platform or chair lifts, widen doorways, roll-in showers)Repairs (e.g., roofing, electrical, carpeting/floors, stair repairs)Home assessmentsRefers to providers (e.g., Home modification program, occupational/physical therapists, funding sources)Raise consumer and/or professional awarenessAdvocacy for home modification policies and fundingParticipate in task forces/coalitions or planning activities with other agenciesIntegrate home modification or repairs within existing home and community-based and/or long-term care programsPartners with state or local non-profit home modification programs (e.g., Rebuilding Together, Habitat for Humanity, etc...)Other(s) (please describe):

Total budget

FUNDING SOURCE(S) (SELECT ALL THAT APPLY)
Older Americans Act Title IIIBOlder Americans Act Title IIIEMedicaid Home and Community-Based WaiverAssistive Technology Act programs/Department of Education (e.g., grants for durable medical equipment)City/County Housing and Community Development Department (e.g., Community Development Block Grants, HOME Block Grants)City/County Department of Housing and Urban Development: Tribes and Tribally Designated Housing EntitiesWeatherization Assistance Program/Department of Energy, State Housing Finance Agency (e.g., home modification loan programs)State Block Grants (e.g., Social Services)State General RevenuesState Funded In-Home Service ProgramState and/or local tax programs (e.g., state sales tax rebates, local tax credits)Local General and Millage FundsPrivate PayFundraisingGrant fundsOther(s) (please describe):

Is your organization non-profit?
yesno

SPECIAL FEATURES (e.g., USE OF AN OCCUPATIONAL THERAPIST; FREE ASSESSMENT; CREATIVE FUNDING; VOLUNTEERS, ETC…)