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FACILITIES OFFICE
Room Prep Questionnaire for Residents with Physical Disabilities

General Information
Name (Last)
Name (First)
Assignment
Phone ( )    -

Have you requested a "Medical Buyout"? A buyout is a double occupancy room as a single occupancy room. All
buyouts must be requested in writing to ORS and must be approved by the Associate Director, Wray VanVoorhis,
937-775-4172.


  • Furniture Removal

Yes No

Please Check those that apply to you:
Desk (Buyout, how many? )
Desk Chair (Buyout, how many? )
Bed frame and mattress (Buyout, how many? )
Dresser/3-drawer unit (Buyout, how many? )
Wardrobe (Buyout, how many? )

* Standard setup for buyout is 2 sets of furniture minus 1 bed frame and mattress *

  • Mark entry door marked with an emergency evacuation sticker

Yes No

  • Install a pull string on the entry door (easier to close door)
Yes No
  • Install an electronic deadbolt on front door of room/apt. (Locks/unlocks standard deadbolt without using a key. Provided free of charge by WSU.
Yes No
  • I will have an electronic door opener. (Resident's responsibility to pay for and contract Modern Entrance 937-431-8141

Yes No

  • Supply personal assistants keys. (3 sets prepared. How many additional keys/sets do you need?

Yes No

  • Supply automatic hallway door clickers (remotes to open your buildings' main entry door and hallway doors
Yes No
  • Adjust bed height so that the mattress is inches off the floor.
    DS or WS bed

 

 

HON, HAH, MAH, PIH, HIH, UP settings:

  • High bed - bottom of bed to floor is 33"
  • Low bed - bottom of bed to floor is 23

BOH, CEH, JAH, OAH settings:

  • High bed - bottom of bed to floor is 27.5"
  • Low bed - bottom of bed to floor is 20

Hamilton Hall and Forest Lane
offers 10 choices of mattress positions

  • Top of mattress to floor
    11" - 38"
  • WOODS AND HONORS
    lower microwave & put it on counter

Yes No

  • WOODS AND HONORS
    remove cabinet fronts so student can roll under sink

Yes No

  • Do you need Braille Labeling

Yes No

Please Check those that apply to you:
Microwave
Stove
Washer and Dryer

  • Other

 

3640 Colonel Glenn Highway - Dayton, Ohio - 45435
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Last updated: Tue. Feb-22-11, 13:38
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