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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. Thisisto request an Environmentalreview fora proposed pr~ectatthefollowing <br /> address: <br /> <br />B. This address is a ( ) Single family home ( ) An apartment Age of bldg. if known <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 <br /> are proposed, check both boxes and identify which improvements are exterior. For <br /> exterior improvements to be made to a building which is at least 50 years old, please <br /> provide a site plan showing the location and extent of the improvements to the building, <br /> a work write-up order and/or plans and specifications of the improvements. <br /> <br /> *Interior means the inside of a home, or an apartment. Exterior means the outside of a <br /> home or a multifamily building. Improvements to be made outside an apartment, but <br /> inside a multifamily family building (such as in hallways, lobbies or stairways) are also <br /> considered "exterior" for this 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 /> ( ) Door knobs ( ) Window latches <br /> ( ) Hinges ( ) Door peepholes <br /> ( ) Bathroom or kitchen faucet ( ) Electronic security systems <br /> ( ) Hand-held shower head ( ) Platform <br /> ( ) Door bell ( ) Trapeze <br /> <br /> Other (Please identify): <br /> <br /> From: Center for Independence of the Disabled (CID) <br /> Contact person and telephone: <br /> <br /> 9/11/03 14 <br /> <br /> <br />