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  • LifeWork™ Adapter Application

  • LifeWork Adapter, LLC

    5114 Balcones Woods Drive, Ste 307-204, Austin, TX 78759 Phone: (512)-601-0513

  • 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.

  • Format: (000) 000-0000.
    • 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.
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  • 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.

  • Format: (000) 000-0000.

  • 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).

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  • 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.                       

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  • 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.                               

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  • 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.

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  • 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.

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