Home modifications assessment form

What it contains

Blank form with supplementary notes and information.

This form is for use by Occupational Therapists providing home modifications assessment services to TAC and WorkSafe Victoria (WorkSafe).

• Approval from the TAC/WorkSafe Agent must be obtained prior to completing a home modifi cations assessment
• Please type or use block letters and ensure that all sections are complete
• All incomplete forms will be returned. Please provide reasons if you are unable to complete a section.