Form 3849, CBA Specifications for Minor Home Modifications

Effective Date: 9/1999

Availability

PDF : 3849.pdf

Instructions

Updated: 9/2004

Purpose

To serve as the primary source document for specifications for minor home modifications purchased by the Home and Community Support Services (HCSS) agency for Community Based Alternatives (CBA) participants.

Procedure

When to Prepare

The HCSS agency must ensure that this form is completed prior to procuring bids for any single minor home modification costing $1000 or more.

Number of Copies

Complete one original for each minor home modification and a copy for the participant.

Transmittal

The original Form 3849 is retained by the HCSS provider, a copy is provided to the participant when he signs the form.

Form Retention

Retain this form according to the terms in the Community Based Alternatives Provider Manual.

Supply Source

This form may be found on the DADS Website.

Detailed Instructions

Note: If Form 3849 is not completed, financial error exceptions may result.

Section I

Participant Name — The HCSS agency enters the participant's name as it appears on page 1 of the participant's Individual Service Plan (ISP) (Form 3671).

Address — The HCSS agency enters the participant's address.

Modifications Needed — The HCSS agency enters a general statement of the modifications needed.

Specifications Required for the Modification — The person writing the specifications for the minor home modification lists the specifications, citing any applicable local regulations, requirements of the construction, and applicable Texas Accessibility (TAS) standards. This is a detailed description of the construction giving degree of angle and length of a wheelchair ramp, for example.

Name of Person Writing the Specifications — The person enters his or her name.

Signature of Person Writing the Specifications — The person must sign and date the form after he has written the specifications.

Section II

The landlord or owner of the property where the minor home modification is to be made must complete this section before the modification is started. The proposed modification must be described in Section I above.

Name of Landlord — Enter the name of the landlord or owner of the property.

Check the appropriate box.

Signature of Landlord — The landlord or owner of the property must sign and date the form.

Note: If the landlord or owner of the property does not approve of the proposed modification, the minor home modification cannot be made on the residence.

Section III

Section III is to be completed by the participant or the responsible party.

Name of Responsible Party — Enter the name of the responsible party, if the responsible party is signing the form.

Check the appropriate box.

Comments: — The participant or responsible party should enter any comments, if applicable.

Signature of Responsible Party — The participant or responsible party must sign and date the form.

CORRECTIONS TO ENTRIES

Method of Correction — To correct an error, line through the error, write the correct entry, and initial the correction. Do not use liquid paper/correction fluid. Original entries, corrections, and initials must be legible.

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