09 832 3727
32a Airdrie Road, Ranui
Auckland
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Rampworx
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Resources
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Site Details Form
Site Details Form
Funding
MOH
Accessable
Enable
ACC
Accessable
Enable
ACC Direct
Rental
ACC
Private
Invacare
Private Purchase
Yes
Client
Name
*
Street Address
Phone
*
Family Contact
Current Location of Client
OT Details
Name
Location
Phone / Fax / Mob
Email
Site Visit
Joint Visit
Yes
No
Date & Time of visit
1
2
3
4
5
6
7
8
9
10
11
12
:
00
01
02
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51
52
53
54
55
56
57
58
59
AM
PM
Family Present
Yes
No
Client Home
Yes
No
Access to Property
Yes
No
Dogs on Property
Yes
No
Mobility
Wheelchair
Power
Manual
Self Propelling
Assisted Walking Frame
Other Mobility Aids
Other information that may help us determine best solution
Amputee
Paralysis
Cognitive Issues
Sight / Speech Impairment
Child / Older Adult
Prognosis
Improve
Decline
Gradient
Gradient
1:12
1:10
Other
Access
Types of Access
Front Door
Back Door
Ranchslider / Bifold / French Doors
Other Entry
Steps
Yes
No
Height (mm)
Made of
Deck
Yes
No
Height (mm)
Made of
Doorway
Joinery
Aluminium
Timber
Other
Sill Width (mm)
Sill Height (mm)
Door Width (mm)
Door Opens
In
Out
Level Access Required?
Yes
No
Screen Door
Yes
No
Direction of Ramp
Parallel with House
To left
To right (looking at house)
Straight out from step / deck
Over lawn
Follow path
End of path / drive
Spaces Available
Access to clothesline
Garage
Backyard
Parking
Carport
Any restrictions in line of proposed ramp?
Restrictions
Downpipes
Taps
Gully traps
Clothesline
Gate
Fence
Opening windows
Under house access
Other doors
Gardens
Trees
Raised Edging
Narrow Access (under 1.2m)
Allow space for 1.2m level area at base of ramp
Site Alterations
Removal of
Fences
Handrails
Trees
Trim
Remove
Gardens
Trim Plants
Remove
Preserve
New Concrete
Pavers
Path
Level area at base of ramp
Making Alterations
Client / family to do
Include in quote
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