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EXHIBIT C <br /> <br /> ENVIRONMENTAL REVIEW FOR <br /> HOUSING ACCESSIBILITY MODIFICATION (HAM) PROJECTS <br /> BY CENTER FOR INDEPENDENCE OF THE DISABLED <br /> <br /> Date: <br /> <br /> A. This is to request an Environmental review for a proposed project at the following address: <br /> <br />B. This address is a ( ) Single family home ( ) An apartment Age of bldg. if known <br /> <br />C. The improvemems to be made to this home/apartment are: ( ) interior* ( ) exterior <br /> <br /> NOTE TO OCCUPATIONAL THERAPIST: If both interior and exterior improvements are <br /> proposed, check both boxes and identify which improvements are exterior. For exterior <br /> improvements to be made to a building which is at least 50 years old, please provide a site plan <br /> showing the location and extem of the imprc{vements to the building, a work write-up order and/or <br /> plans and specifications of the improvements. <br /> <br /> *interior means the inside of a home, or an apartment. Exterior me'ns the outside of a home or a <br /> multifamily building. Improvements to be made outside an apartment, but inside a multifamily <br /> family building (such as in hallways, lobbies or stairways) are also considered "exterior" for this <br /> purpose. <br /> <br />D. The improvements will consist of the installation or construction of: <br /> <br /> ( ) Grab bars ( ) Emergency alert system <br /> ( ) Wooden banister ( ) Smoke detectors <br /> ( ) Medal Handrail ( ) Non-skid surfaces <br /> ( ) Prefabricated ramp ( ) Dead bolts <br /> ( ) Wooden ramp ( ) Door bell <br /> <br /> ( ) Door knobs ( ) Window latches <br /> ( ) Hinges ( ) Door peepholes <br /> ( ) Bathroom or kitchen faucet ( ) Electronic security systems <br /> ( ) Hand-held shower head ( ) Platform <br /> ( ) Doorbell ( ) Trapeze <br /> <br /> Other (Please identify): <br /> <br />From: Center for Independence of the Disabled (CID) <br /> Contact person and telephone: <br /> <br /> <br />