Site evaluation worksheet – EZ-ACCESS PATHWA MODULAR ACCESS SYSTEM User Manual
Page 8
Page | 8
S I T E E V A L U A T I O N
SITE EVALUATION WORKSHEET
SECTION 1 - JOB SITE & END-USER INFORMATION
TODAY’S DATE
END USER LAST NAME
END USER FIRST NAME
TELEPHONE
JOB SITE ADDRESS
CITY
STATE
ZIP
SECTION 2 – EVALUATOR INFORMATION
EVALUATION DATE
EVALUATION COMPANY NAME
EVALUATOR’S NAME
TELEPHONE
EVALUATOR’S ADDRESS
CITY
STATE
ZIP
SECTION 3 – CONSIDER THE FOLLOWING
TOTAL RISE
ENTRANCE
FRONT
REAR
SIDE
GARAGE
SCALE: 1 SQUARE = 1 FOOT (BE SURE TO NOTE OBSTACLES SUCH AS DRIVEWAY, SIDEWALKS, TREES, SHRUBS, ETC.)
NOTES
FAX
1-800-630-2350 •
PHONE
1-800-451-1903
© Homecare Products, Inc. All rights reserved. All text and images contained on this document are proprietary and may not be shared,
modified, distributed, reproduced, or used without the express written permission of EZ-ACCESS.