BPM006728_Exhibit_H_-_RSA__HM_Project_Completion_Report.pdf
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- Attached to
- Master Agreement AZ|CTR077216
- Contract number
- CTR077216
- Issued by
- Arizona
About this file
This document is a Home Modification Project Completion Report from the Arizona Department of Economic Security (ADES), specifically the Rehabilitation Services Administration (RSA). The form is designed to document and track home modification projects for individuals with disabilities, involving a contractor, client, evaluator, and various administrative personnel from the RSA program.
The report provides a comprehensive template for documenting home modification services, including potential modifications to entry/exit areas, bedrooms, bathrooms, and other home spaces such as kitchens or garages. The form requires detailed documentation of services performed, including photographic evidence, project start and completion dates, and multiple levels of certification and signature. It includes sections for the contractor to detail the project, the client to confirm satisfaction, an evaluator to verify disability-related needs were met, and signature lines for multiple stakeholders to validate the project's completion according to specified service recommendations.
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Text version
Exhibit H
V1_RSA Project Completion Report
Arizona Department of Economic Security (ADES) Rehabilitation Services Administration (RSA)
HOME MODIFICATION
PROJECT COMPLETION REPORT
SECTION I: TO BE COMPLETED BY CONTRACTOR
Project Summary: Check applicable boxes and include photos below:
Entry/Exit:
☐ Ramp
☐ Stairs
☐ Power door opener(s)
☐ Handrails
☐ Other
Bedroom:
☐ Doorway
☐ Handrails
☐ Grab bars
☐ Overhead lift
Bathroom:
☐ Doorway
☐ Toilet
☐ Shower
☐ Sink
☐ Grab bars
Other:
☐ Kitchen
☐ Laundry
☐ Office
☐ Garage
Insert photos into the completion document or attach additional pages of pictures, labeled to numbered specifications.
Service/Task Service/Task Description
Photos:
Project Number:
CONTRACTOR INFORMATION:
Name: _________________________________ Phone Number: ____________________________
RSA Purchase Authorization Number: ___________________ Date Received: _________________
Project Start Date (mutually agreed by Client & Contractor): ________________________________
Project Completion Date: (if not completed within 30 calendar days of Start Date, please include explanation:
Photos:
SECTION II: TO BE COMPLETED BY CLIENT
SECTION III: TO BE COMPLETED BY THE EVALUATOR
SECTION IV: SIGNATURES
The following parties certify that this home modification project has been completed according to the service specification recommendations.
Client’s Signature: ____________________________________________ Date: __________
Evaluator’s Signature: _________________________________________ Date: __________
Home Modification Coordinator Signature: _________________________ Date: __________
VR Counselor’s (or designee) Signature: __________________________ Date: __________
Other (role) Signature: _________________________________________ Date: __________
Client Name: ________________ Phone Number: ______________ Email: ____________________
Adress: __________________________________________________________________________
Has training been provided in the use of any equipment and modification?
☐ Yes ☐ No Comment(s): _________________________________________________________
Has any equipment manuals and/or warranty documentation been provided (if applicable)?
☐ Yes ☐ No Comment(s): _________________________________________________________
Is the workmanship satisfactory?
☐ Yes ☐ No Comment(s): _________________________________________________________
Evaluator: _________________ Phone Number: ________________ Email: ___________________
Have prescriptive items been installed to meet the disability related needs per evaluator’s recommendations?
☐ Yes ☐ No Comment(s): _________________________________________________________
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