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<br />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. ifknown <br /> <br />C. The improvements 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 extent ofthe improvements to the building, a work write-up order and/or <br />plans and specifications of the improvements. <br /> <br />*lnterior means the inside of a home, or an apartment. Exterior means 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 <br />( ) Wooden banister <br />( ) Medal Handrail <br />( ) Prefabricated ramp <br />( ) Wooden ramp <br /> <br />( ) Emergency alert system <br />( ) Smoke detectors <br />( ) Non-skid surfaces <br />( ) Dead bolts <br />( ) Door bell <br /> <br />( ) Door knobs <br />( ) Hinges <br />( ) Bathroom or kitchen faucet <br />( ) Hand-held shower head <br />( ) Door bell <br /> <br />( ) Window latches <br />( ) Door peepholes <br />( ) Electronic security systems <br />( ) Platform <br />( ) Trapeze <br /> <br />Other (Please identify): <br /> <br />From: Center for Independence of the Disabled (CID) <br /> <br />Contact person and telephone: <br />