LifeWork Adapter Application

Before starting this application, please review the LifeWork™ Adapter website to learn more about the LifeWork™ Adapter.

The website will provide a better perspective of the capabilities of the LifeWork™ Adapter.

The information below will allow you to determine if you need additional equipment that is required to operate the LifeWork™ Adapter Power Tool Kit. If additional equipment is needed, LifeWork™ Adapter will work with you to ensure you have what is needed to safely operate the tools.

Complete each section below and someone from LifeWork Adapter will be in touch with you to gather additional information needed to ensure a proper fit.

All questions, comments, or concerns you may have regarding any additional equipment are welcome. There is a comment section at the end of the form to use, if needed, or you may email info@lifeworkadapter.com.

Name

First NameLast Name

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Military or First Responser Status*

Military or Military VeteranFirst Responder or First Responder Veteran

Military: DD214 OR current ID Card - please hide the Social Security number.
EMTs/Paramedics can use a state license, a EMT / Paramedic certification issued within the past 48 months, or an ID Card with their name and title on it.
Firefighters can use an ID card with their name and title on it, a firefighter certification issued within the past 48 months, or an unexpired membership card.
Law Enforcement Officers (LEOs) can use a valid ID card that states their name and title, a pay stub that shows their occupational title, or a LEO certification issued within the past 48 months. Federal LEOs can use your SF-50.
911 Dispatchers can use an ID Card with their name and title on it or a 911 Dispatcher certification issued within the past 48 months.
Correctional Officers can use a valid ID card that states their name and title, a pay stub that shows their occupational title, or a Correctional Officer certification issued within the past 48 months.
Retired First Responders can use a retiree ID card, retirement certificate, etc.

Upload proof of Active Duty or Retired Status.

QUESTION: Do you belong to a non-profit organization that supports veterans or first responders? If so, please provide the name of the organization, Case Manager’s (CM) Name, and their Contact Information.

Organization

Case Manager

Case Manager Email

example@example.com

Case Manager Phone Number

Please enter a valid phone number.

Hosmer 5x or 8 Stainless Steel Hook

The Hosmer 5x or 8 Stainless Steel Hook is REQUIRED to operate the LifeWork™ Adapter Power Tool kits. The Hosmer Hooks depicted below are by Fillauer (fillauer.com).

Do you CURRENTLY HAVE a 5x or 8 Hosmer Stainless Steel Hook?

YESNO

If you CURRENTLY HAVE a 5x or 8 Hosmer Stainless Steel Hook, which do you have?

5x8Do not know

On which side of your body do you wear the hook?

LEFTRIGHT

Body-Powered Prosthetic Simulator

The Body-Powered Prosthetic Simulator below is used in cases of limited use of the hand, partial loss of function, or missing digits when using the Hosmer 5x or 8 stainless steel hook. The Body-Powered Prosthetic Simulator depicted below is available from TRS Prosthetics.

Do you CURRENTLY HAVE a Body-Powered Prosthetic Simulator of any kind that can accept a Hosmer Hook?

YESNO

On which side of your body do you wear the body-powered prosthetic simulator?

LEFTRIGHT

Arm Cuff

This device is called an arm cuff. The arm cuff is used for injuries below the wrist and can be adapted to the Hosmer 5x and 8 Stainless Steel Hook to use with the LifeWork™ Adapter Tool Kit. The arm cuff depicted below is available from TRS Prosthetics.

Do you have an arm cuff?

YESNO

On which side of your body do you wear the arm cuff?

LEFTRIGHT

Please provide any additional information you would like to provide.

Information provided in this application will be shared with LifeWork Adapter LLC and the non-profit organization that is funding your free adaptive power tool kit.

Information provided in this application will not be sold to any company for marketing purposes.

Information from the application will be used to contact you to get additional information from you to ensure the free adaptive power tool kit will fit you and your needs.

For a full details of our privacy policy please visit our website (www.lifeworkadapter.com). By signing below you agree to the privacy policy.

Please sign below the application below.

For videos and other links to see how the system works please go to www.lifeworkadpater.com.

You can also contact us at Info@lifeworkadapter.com.

To see how the LifeWork™ Adapter Power Tool Kit is authorized by the US Department of Labor, Justified Accommodation Network (JAN), click the following link: https://askjan.org/vendors/LifeWork-Adapter.cfm.

JAN provides free consulting services for all employees, regardless of the medical condition. Services include one-on-one consultation about all aspects of job accommodations, including the accommodation process, accommodation ideas, product vendors, referral to other resources, and ADA compliance assistance. You can learn more at https://askjan.org/about-us/index.cfm.

LifeWork™ Adapter Application

LifeWork Adapter, LLC