Redbridge e-forms Independent Living Grant You cannot proceed with this application! If you have not yet been assessed by an Occupational Therapist, please complete this online form to request assessment for adults, or visit this website to request an assessment for a child. Confirmation(Required) Please confirm that you have been assessed by an occupational therapist (OT). Occupational Therapist AssessmentName of the OT visitedDate of visit Day Month Year Information about the grant You may receive a maximum of £19,000 dependent on what we decide is a reasonable cost for the work you need. If you require assistance completing the form, please contact the Home Improvement Team. Confirmation(Required) I understand that no work should be carried out until I have written confirmation of grant approval. What will we do with information you provide? The Home Improvement Team of the London Borough of Redbridge will be collecting this information to process your application for a grant. Some of the data we collect will be personal data about you. This will include amongst other things: name, residential address and date of birth. We will also collect details of household income, benefits and all those living at your address. We review our retention periods of the information we hold about you on a regular basis. We are legally required to hold some types of information to fulfil our statutory obligations. We will hold your personal information on our systems for as long as it is necessary for the service that we provide to you, or as required by law. The information you provide may be shared with other enforcement agencies and local authorities nationally where breaches of statutory legislation are suspected. We may also be obligated to share your personal details with other organisations for crime and taxation purposes including for the prevention or detection of crime, the capture or prosecution of offenders; and the assessment or collection of tax or duty under section 29 of the Data Protection Act. We will not use your information for marketing. Further information on how we process your data and your rights can be found in our privacy policy online Who is the adaption for?Is the disabled adaption work for a child?(Required) Yes No Child's First name(Required)Child's Last name(Required)Child's Date of Birth(Required) Day Month Year Your detailsYour (Disabled person's) detailsTitle(Required)Please selectMrMrsMissMsOtherIf other, please specify(Required)First Name(Required)Last Name(Required) Your detailsYour (Disabled person's) detailsDate of Birth(Required) Day Month Year National Insurance Number(Required) Your detailsYour (Disabled person's) detailsEmail address(Required) Telephone Number(Required) Your detailsYour (Disabled person's) detailsAre you a student ?(Required) Yes No Marital Status(Required) Single Married/Partner/living together Marital status refers to the relationship you have with the partner you live with. For the purpose of this form, partner includes both same sex partners and partners of the opposite sex, whether married or living together. Your property detailsYour (Disabled person's) property detailsWhat is the property address where the grant works will be carried out?(Required)Find addressSelected address Do you own the above property?(Required) Yes No Please enter the details of the owner (Private landlord’s name or Housing association name)(Required)Does anyone else share ownership of the above property?(Required) Yes No Shared ownershipPlease give details of the person sharing ownership of the propertyTitle(Required)Please selectMrMrsMissMsOtherIf other, please specify(Required)First Name(Required)Last Name(Required) Spouse/Partner detailsTitle(Required)Please selectMrMrsMissMsOtherIf other, please specify(Required)First name(Required)Last name(Required) Spouse/Partner detailsDate of Birth(Required) Day Month Year National Insurance Number(Required) Spouse/Partner detailsEmail address(Required) Telephone number(Required) Spouse/Partner detailsIs your Spouse/Partner a student ?(Required) Yes No Other household membersPlease list all the people who live in your home (other than you and your Spouse/Partner)NameRelationship to you(e.g. son, daughter)Date of BirthWhat they do (e.g. work, school, student)Please state if disabled or have long term serious illness Add Remove Contact someone else on your behalfDo you want us to contact someone else on your behalf e.g. friend, family? Yes No Title(Required)Please selectMrMrsMissMsOtherIf other, please specify(Required)First name(Required)Last name(Required)Telephone number(Required) Choosing a contractorPlease select your preferred method.(Required) I would like the Council to arrange to carry out the works on my behalf by sourcing a contractor. The Council operates a Dynamic Purchasing System (DPS) to support applicants and those in need of minor building works to meet their home environmental needs in engaging with reputable and compliant contractors. Independence Community Interest Company manage the DPS on behalf of the London Borough of Redbridge. I would like to source my own contractor to undertake the adaptation work. I understand that I will be required to submit 2 or 3 quotations for the adaptation(s) from an approved contractor to ensure that the grant awarded is fair value. I understand that I must provide an itemized quotation to demonstrate that I have met the schedule of works. I will also need to provide a valid invoice in order for the Council to pay the grant. It is important to note that as the work is being carried out on your home the contract for works will be between you and the contractor. This means the council is not responsible should you have and dispute with a contractor during or after the works are complete. Diversity Monitoring Form The London Borough of Redbridge is committed to equality in all its activities and responsibilities. This means taking action to ensure that all Council services are accessible and that all users of Council services are treated fairly. The information you give on this form will remain strictly confidential, in accordance with the Data Protection Act 1998. Gender Male Female Is your gender identity the same as at birth? Yes No Age 0-17 18-24 25-34 35-44 45-54 55-64 65+ Diversity MonitoringDo you consider yourself to have a disability ? Yes No Please select the disability you have(Required) Hearing Reduced Mobility Mental health Illness Speech Other disability If other disability, please specify(Required) Diversity MonitoringSexual Orientation Heterosexual Lesbian Gay Bi-sexual Prefer not to say Religion/Belief Christian Jewish Muslim Sikh Buddhist Hindu None Any other religion Diversity MonitoringEthnicity White British White Irish White Scottish White Welsh Gypsy Irish Traveller Any other White background White and Caribbean White and African White and Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Black/Black British Black Caribbean Black African Any other black background Chinese Any other ethnic group Declaration(Required) I declare that to the best of my knowledge, the information I have provided above is correct.