Housekeeping Allowance Reassessment/Followup

Housekeeping Allowance Reassessment/Followup

Worker’s (Surname) / (First Name) / (Initial) / Claim Number

P.O. BOX 2415EDMONTON, AB T5J 2S5
FAX:(780) 427-5863
1-800-661-1993 /

C1173

OCCUPATIONAL THERAPY SERVICES

Housekeeping AllowanceReassessment/Followup

Please print clearly or type. / WCB Claim Number / Personal Health Number / Date of Accident (yyyy/mm/dd)
Worker’s Surname / First Name / Initial / Date of Birth (yyyy/mm/dd)
Address Street / City/Town / Province / Postal Code / Telephone Number
Claim Owner’s Name / Telephone Number / Date of Referral(yyyy/mm/dd)
Provider’s Contact Name / Telephone Number / Assessment Date (yyyy/mm/dd)
General

Referral Questions

Work Related Injury and Disability

Injuries or conditions not related to the claim

Brief History

Worker’s Height (inches)Weight (lbs)

Physical and Functional Assessment

Living situation

1.Type of Residence:

Trailer/Mobile home Apartment Town house/Condominium Bungalow

Split level Two storey Other (Specify):

2.Ownership

Owned Rented

3.Living Arrangement

Lives alone Lives with family/friend

pre-injury home maintenance status

What home maintenance AND housekeeping activities did the worker perform prior to the injury?

What home maintenance activities AND housekeeping activities were done by others (family, friends, hired out)?

ASSESSMENT:

Which housekeeping activities that were previously completed by the client is the client

unable to perform now due to the work-related injury/disability?

Independent / Dependent
Cleaning behind appliances
Washing walls/windows
Scrubbing floors, bathroom etc.
Vacuuming

Other (Specify):

What physical impairment/functional limitations are impacting the client’s ability to perform the home maintenance activities outlined above?

Are there assistive devices that could be provided to the worker that would help them become more independent?

Recommendations

Please discuss any recommendations with the claim owner prior to finalizing the report.

If you have any questions regarding the information or would like to discuss, please contact the undersigned.

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Provider’s Name / Telephone Number / Date (yyyy/mm/dd)

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.

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