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Prescribing Equipment - by Document Type

Checklists

Checklist For Prescribers Submitting Equipment Requests (MS Word Document 165.7 KB)
Checklist For Prescibers Submitting Home Modification Requests (MS Word Document 168.1 KB)

Clinical Considerations for Prescribers

Bariatric Equipment Clinical Considerations for Prescribers (MS Word Document 145.5 KB)
Bath Aids Clinical Considerations for Prescribers (MS Word Document 131.0 KB)
Bathroom Clinical Considerations for Prescribers (MS Word Document 162.5 KB)
Bathroom Electrical Safety Clinical Considerations for Prescribers (MS Word Document 300.0 KB)
Bed Assessment Clinical Considerations for Prescribers (MS Word Document 120.5 KB)
Bed Pan Clinical Considerations for Prescribers (MS Word Document 124.0 KB)
Bed Rails Clinical Considerations for Prescribers (MS Word Document 325.5 KB)
Bed Sticks Clinical Considerations for Prescribers (MS Word Document 388.5 KB)
Car Hoist and Wheelchair Carriers Clinical Considerations for Prescribers (MS Word Document 137.0 KB)
Chair Bed Blocks or Bed Raiser Clinical Considerations for Prescribers (MS Word Document 227.0 KB)
Chair Raiser Clinical Considerations for Prescribers (MS Word Document 230.5 KB)
Clinical Considerations for Use of Exercise Pedals (MS Word Document 94.0 KB)
Commodes Clinical Considerations for Prescribers (MS Word Document 130.5 KB)
Motor Vehicle Transport of People in Wheelchairs (MS Word Document 163.5 KB)
Electric Recliner Lift Chair Clinical Considerations for Prescribers (MS Word Document 133.0 KB)
Grab Rails Clinical Considerations for Prescribers (MS Word Document 148.5 KB)
Hoists Clinical Considerations for Prescribers (MS Word Document 161.0 KB)
Kitchen Clinical Considerations for Prescribers (MS Word Document 148.5 KB)
Manual Wheelchairs Clinical Considerations for Prescribers (MS Word Document 153.5 KB)
Mobile Shower Chair Clinical Considerations for Prescribers (MS Word Document 146.0 KB)
Overway Bedtable Clinical Considerations for Prescribers (MS Word Document 134.5 KB)
Postural Chairs Clinical Considerations for Prescribers (MS Word Document 148.0 KB)
Pressure Mattresses Clinical Considerations for Prescribers (MS Word Document 156.0 KB)
Pressure Reduction Comfort Chairs Clinical Considerations for Prescribers (MS Word Document 139.0 KB)
Ramps Clinical Considerations for Prescribers (MS Word Document 156.0 KB)
Scooters Clinical Considerations for Prescribers (MS Word Document 134.5 KB)
Shower Chairs Clinical Considerations for Prescribers (MS Word Document 200.5 KB)
Shower Hoses Clinical Considerations for Prescribers (MS Word Document 135.0 KB)
Slings Clinical Considerations for Prescribers (MS Word Document 145.5 KB)
Steps Clinical Considerations for Prescribers (MS Word Document 146.5 KB)
Strollers Clinical Considerations for Prescribers (MS Word Document 152.5 KB)
Toiletting Aids Clinical Considerations for Prescribers (MS Word Document 135.5 KB)
Traymobile Clinical Considerations for Prescribers (MS Word Document 135.0 KB)
Utility Chairs Clinical Considerations for Prescribers (MS Word Document 136.0 KB)
Walkers Clinical Considerations for Prescribers (MS Word Document 137.5 KB)
Walking Aids Clinical Considertions for Prescribers (MS Word Document 135.5 KB)
Wheelchair and Plinth (MAT) Clinical Considerations for Prescribers (MS Word Document 207.0 KB)

Criteria Screening Tools

Criteria Screening Tool, Hoist (MS Word Document 62.1 KB)
Criteria Screening Tool, Electrically Operated Bed (MS Word Document 64.4 KB)
Criteria Screening Tool, Electric Riser Recliner Chair (MS Word Document 132.0 KB)
Criteria Screening Tool, Modified Driving Controls (MS Word Document 55.6 KB)
Criteria Screening Tool, Scooter (MS Word Document 146.5 KB)
Criteria Screening Tool, Wheelchair Carrier (MS Word Document 64.6 KB)

Fact Sheets

Applying a Plastic Sheet Over Electrical Outlets Fact Sheet (MS Word Document 154.0 KB)
Client Information Access to Interpreting Service Reference Guide (MS Word Document 100.0 KB)
Client Information Privacy and Personal Information Statement (MS Word Document 54.9 KB)
Client Information Your Rights and Responsibilities Form (MS Word Document 72.5 KB)
Consumers With Disability—Where to go for advice or complaints (PDF 328.8 KB)
Mobility Vehicle Modifications SA Service Providers Reference Guide (MS Word Document 2.4 MB)
Wheelchairs Motor Vehicle Transportation Fact Sheet (MS Word Document 559.5 KB)
Wheelchairs Out and about Fact sheet (MS Word Document 788.5 KB)

Flyers

Orientation to DES and the DHS Equipment Program Flyer (PDF 395.4 KB)

Forms - Agreement

Electronic Door Opener Specification and Agreement Form (MS Word Document 841.1 KB)
Equipment Selection Agreement Form (MS Word Document 92.6 KB)
Major Home Modification Satisfactory Completion Agreement Form (MS Word Document 47.1 KB)

Forms - Assessment

Bed, Mattress and Bed Equipment Assessment Form (MS Word Document 306.0 KB)
Car Hoist and Wheelchair Carrier Assessment (MS Word Document 95.6 KB)
DHS EP ACC Client Registration Form (MS Word Document 98.2 KB)
Advanced Palliative Equipment Response Assessment Request Form (MS Word Document 124.4 KB)
Electric Recliner Lift Chair Assessment form (MS Word Document 597.0 KB)
Hoist Assessment Form (MS Word Document 203.0 KB)
Major Bathroom Modification Assessment Form (MS Word Document 157.5 KB)
Major Kitchen Modification Assessment Form (MS Word Document 126.5 KB)
Medical Information Form (MS Word Document 197.0 KB)
Mobile Shower Commode Chair Assessment Form (MS Word Document 532.3 KB)
Plinth (MAT) Assessment Form (PDF 1.4 MB)
Powered Mobility Formal Tests (MS Word Document 105.0 KB)
Powered Mobility Practical Assessment Form (MS Word Document 122.0 KB)
Pressure Reduction/Comfort Chair Assessment Form (MS Word Document 413.3 KB)
Scooter Assessment Form (MS Word Document 54.9 KB)
Sling Assessment Form (MS Word Document 189.0 KB)
Wheelchair Initial Assessment Form (MS Word Document 294.5 KB)

Forms - Delegate approval

Delegate Approval Request Form (MS Word Document 172.7 KB)

Forms - Other

Client Information Feedback Form (MS Word Document 57.3 KB)

Forms - Prescriber registration

Recognition of Prior Learning Assessing and Prescribing Adjustable Beds (MS Word Document 135.0 KB)

Forms - Prescription

Advanced Palliative Equipment Response Client Registration Form (MS Word Document 94.1 KB)
Beds checklist’ to Checklist for the Prescription of Electric Beds for APER Clients (MS Word Document 344.2 KB)
Equipment Request Form DHS Equipment Program (MS Word Document 149.3 KB)
Home Modification Request and Agreement Form DHS Equipment Program (MS Word Document 97.2 KB)
DHS Equipment Program Wig Request Form (MS Word Document 62.8 KB)
Equipment Request 2023 01 24 (MS Word Document 143.1 KB)
Equipment Request Form LSA (MS Word Document 194.8 KB)
Equipment Request Form RDNS (MS Word Document 146.7 KB)
Imprest Trial and Prescription Form Marla DES Store (MS Word Document 126.0 KB)
Medical Grade Footwear and Lower Limb Orthoses Request Form 2023 04 04 (MS Word Document 167.4 KB)

Forms - Priority

Priority Scoring Communication and Assistive Technology (MS Word Document 170.8 KB)
Risk Rating and Priority Scoring Form (MS Word Document 126.3 KB)

Forms - Repairs / Collections

Equipment Collection Request (MS Word Document 161.0 KB)
Equipment Write off Request Form (MS Word Document 116.6 KB)
Repair Contingency Plan Highly Customised Equipment (MS Word Document 153.0 KB)

Forms - Specifications

Bidet Specification and Agreement Form (MS Word Document 375.0 KB)
Ceiling Hoist Specification and Agreement Form (MS Word Document 145.9 KB)
Customised chair form 2023 01 24 (MS Word Document 89.1 KB)
General Seating Initial Specification Form (MS Word Document 1.7 MB)
Generic Specification Form (MS Word Document 116.5 KB)
Home Modification Specification Form Bathroom / Toilet (MS Word Document 144.0 KB)
Home Modification Specification Form Internal Access Doorway Widening (MS Word Document 121.0 KB)
Home Modification Specification Form Kitchen (MS Word Document 124.5 KB)
Home Modification Specification Form Long Ramp (MS Word Document 149.5 KB)
Home Modification Specification Form Major Step (MS Word Document 118.0 KB)
Minor Access Home Modification Specification Form (MS Word Document 163.0 KB)
Minor Home Modification Blank Specification Form (MS Word Document 90.0 KB)
Mobile Shower Chair Seat Modifications Specification Form (MS Word Document 314.0 KB)
Scooter Specification Form (MS Word Document 98.1 KB)
Shower Platform Specification Form (MS Word Document 94.0 KB)
Wheelchair Initial Specification Form (MS Word Document 1.7 MB)

Forms - Tracking / Transfer

Equipment Transfer Update Form RDNS or External Agency (MS Word Document 79.1 KB)
General Equipment and Home Modification Review (MS Word Document 46.4 KB)
Transferring Ownership of Equipment Items from DHS Terms and Conditions Agreement Form (MS Word Document 53.9 KB)
Transferring Ownership of Equipment to DHS Terms and Conditions Agreement (MS Word Document 123.0 KB)

Procedures/Guidelines

Accessing a Wheelchair and Seating Service (MS Word Document 388.5 KB)
Accessing the Equipment Program step by step guide (MS Word Document 178.8 KB)
Completing Clinical Review of Equipment (MS Word Document 446.5 KB)
Completing Clinical Reviews of Home Modifications (MS Word Document 393.5 KB)
Completing Follow Up of Equipment (MS Word Document 435.5 KB)
Completing Follow Up of Home Modifications (MS Word Document 445.0 KB)
Completing General Review of Equipment (MS Word Document 341.5 KB)
Completing Powered Mobility Aid Clinical Review (MS Word Document 409.5 KB)
Consultant and Clinician Roles in Major Home Modifications (MS Word Document 90.0 KB)
Determining Eligibility for Home Modification (MS Word Document 401.5 KB)
Funding of Additional Features to Equipment by Client (MS Word Document 393.0 KB)
Funding of Additional Home Modification Features by Client (MS Word Document 341.0 KB)
How Often Do a Client's Powered Mobility Aid Skills Need Review? (MS Word Document 141.0 KB)
How To Complete the Scooter and Wheelchair Specification Form (MS Word Document 120.0 KB)
Indicators For Medical Clearance of Powered Mobility Devices (MS Word Document 136.0 KB)
Powered Mobility Frequency of Clinical Review Indicators (MS Word Document 145.0 KB)
Prescribing a Home Modification (MS Word Document 484.0 KB)
Priority Score Guidelines Adults Equipment (MS Word Document 137.5 KB)
Requesting Repairs, Maintenance and Replacement of Home Modifications (MS Word Document 328.0 KB)
What are Major and Minor Home Modifications (MS Word Document 125.5 KB)
When does a technician and or specialist need to be accessed (MS Word Document 119.5 KB)

Reference Documents - Prescription

Access and Mobility Reference Charts AS1428.1 (MS Word Document 77.4 KB)
Bathroom Electrical Safety Training Resource Kit (MS Word Document 1.5 MB)
Bed Entrapment Zone Measuring Tool (MS Word Document 3.0 MB)
Braden Pressure Risk Scale (PDF 958.4 KB)
Circulation Spaces at Doorways Appendix C AS1428 1 2001 (MS Word Document 417.7 KB)
Circulation Spaces at Doorways Fig 1 AS1428 1 2009 (MS Word Document 371.2 KB)
Cushion Comparison Table (MS Word Document 101.6 KB)
Electric Adjustable Bed Comparison Table (MS Word Document 451.1 KB)
Entrapment Zone Compliance Matrix (MS Word Document 79.2 KB)
Guide to Assessing Entrapment Risk (MS Word Document 122.5 KB)
Guide to Assessing Pressure Risk Tool (MS Word Document 123.5 KB)
Initial Considerations for an Electric Bed Prescription (MS Word Document 61.5 KB)
Instructions for Measuring Entrapment Zones (MS Word Document 2.2 MB)
Modifying Equipment Example List. (MS Word Document 93.1 KB)
ROHO Cell to Seat Size Convert (PDF 514.8 KB)

Reference Documents – Accessing Services

Equipment Supply Suburb Listing for Metropolitan Adelaide (MS Word Document 172.0 KB)

Service Information and Terms and Conditions

Care and Use of a Powered Mobility Aid (MS Word Document 139.5 KB)
Equipment Program Terms and Conditions of Installation of Home Modifications (MS Word Document 104.3 KB)
Information for Provision of Home Modifications (MS Word Document 60.2 KB)
Major Home Modification Client Information Sheet (MS Word Document 166.1 KB)
Terms and Conditions and Information on Use of Equipment (MS Word Document 86.9 KB)

Specific Eligibility Criteria

Specific Eligibility Criteria Car Hoist (Person Lift Only) (MS Word Document 129.5 KB)
Specific Eligibility Criteria Ceiling Hoists (MS Word Document 109.5 KB)
Specific Eligibility Criteria Electric Beds (MS Word Document 100.5 KB)
Specific Eligibility Criteria Electric Riser Recliner Chairs (MS Word Document 65.2 KB)
Specific Eligibility Criteria Eye Gaze Technology (MS Word Document 161.0 KB)
Specific Eligibility Criteria Foot Orthoses and Ankle Foot Orthoses (MS Word Document 173.5 KB)
Specific Eligibility Criteria Long Ramps (MS Word Document 88.5 KB)
Specific Eligibility Criteria Major Access Modifications (MS Word Document 82.0 KB)
Specific Eligibility Criteria Major Bathroom Modifications (MS Word Document 88.5 KB)
Specific Eligibility Criteria Major Kitchen Modifications (MS Word Document 60.3 KB)
Specific Eligibility Criteria Major Step Modifications (MS Word Document 86.5 KB)
Specific Eligibility Criteria Manual Wheelchairs (MS Word Document 113.0 KB)
Specific Eligibility Criteria Medical Grade Footwear (MS Word Document 114.3 KB)
Specific Eligibility Criteria Modified Driving Controls (MS Word Document 109.0 KB)
Specific Eligibility Criteria Posture Chairs (MS Word Document 134.5 KB)
Specific Eligibility Criteria Provision of a Powered Mobility Aid and a Manual Wheelchair or Non Standard Stroller (MS Word Document 64.2 KB)
Specific Eligibility Criteria Powered Mobility Aids for Outdoor Use (MS Word Document 144.5 KB)
Specific Eligibility Criteria Powered Wheelchairs (MS Word Document 156.5 KB)
Specific Eligibility Criteria Rehabilitation Equipment (MS Word Document 113.5 KB)
Specific Eligibility Criteria Roof Mounted Wheelchair Carriers (MS Word Document 130.5 KB)
Specific Eligibility Criteria Speech Generating Devices (MS Word Document 130.5 KB)
Specific Eligibility Criteria Strollers (MS Word Document 148.5 KB)
Specific Eligibility Criteria Technology (Computer Access) (MS Word Document 119.5 KB)
Specific Eligibility Criteria Technology (Environmental Control Systems) (MS Word Document 139.5 KB)
Specific Eligibility Criteria Towbar Mounted Wheelchair Carriers (MS Word Document 117.5 KB)
Specific Eligibility Criteria for the Provision of Wigs (MS Word Document 46.6 KB)

Templates

Bath Grab Rail Template Left Side (MS Word Document 215.5 KB)
Bath Grab Rail Template Right Side (MS Word Document 182.5 KB)
Shower Grab Rail Template (MS Word Document 80.5 KB)
Toilet Measurements Template (MS Word Document 95.0 KB)
Toilet Rail Template Left Side (MS Word Document 77.5 KB)
Toilet Rail Template Right Side (MS Word Document 78.0 KB)
Toilet Template Front View (MS Word Document 85.5 KB)

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Last updated:01 Nov 2023 9:03pm

Government of South Australia

This site is licensed under a Creative Commons Attribution 4.0 Licence. © DHS . Back to top

Last updated:06 Nov 2023 11:47am

Government of South Australia

Provided by:

Department of Human Services

URL:

https://equipmentprogram.sa.gov.au/lists/dhs-equipment-program-documents/prescribing-equipment-by-document-type

Last Updated:

27 Mar 2018

Printed on:

22 Feb 2025

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Government of South Australia