Application for Specialized Telecommunications Assistance Program (STAP) Speech Generating Devices

Division for Rehabilitation Services Office for Deaf and Hard of Hearing Services

Step 1Provide Applicant Information Applicants full first name: Middle name: City: Street address (PO Box is not acceptable): Home telephone number: () TX drivers license number: Parent or legal guardian name:

Last name: State:

ZIP code:

Alternate telephone number: () Birth date:

TX Social Security number: Email:

Mailing Address (if different from above) Name: Address: City:

State:

ZIP code:

If you provide a different mailing address, or a parent or guardian signs the application, then enter X to select one: Applicant (PO Box) x Guardian or family member

Specify the persons relationship to the applicant. Parent Signature. Unless the applicant signs the application or provides proof of residency in the applicants name, the same person must both sign the application and provide proof of residency. This application must have an original signaturenot a photocopy, facsimile, or stamped signature. If you are less than 18 years old, the parent or guardian must sign the application.

The following statement must be signed before the application can be processed. I attest to the following:

The applicant is a Texas resident. The applicant requires a specialized adaptive device(s) to access the telephone network. The device selected will enable the applicant to access the telephone network.

I understand that STAP may request additional documentation as needed to confirm or supplement any information provided on the application, including physicians statements or medical records.

All information given on this application is true.

Signature of applicant, parent, or legal guardian:

Printed name:

Date:

Mail to: STAP, PO Box 12904, Austin, TX 78711

This application form is valid until August 31, 2013

Application for STAP Speech Generating Devices

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Step 2Provide Proof of Residency

Include a copy of one of the following as proof of your Texas residency. Document must be current and dated within 3 months of the date the application is signed. Medicaid ID Texas drivers license utility bill (showing address) ID card with address Medicare Summary voter registration card vehicle registration card letter on the official letterhead of a residential facility signed by the facility director or supervisor

Proof of residency must name the applicant, parent, or legal guardian signing the application and show the home address as it appears on the application.

Step 3Device Options

You must meet the established disability requirements for the device requested. Note: these disability requirements are defined in the form instructions. SI = Speech impaired UMI = Upper mobility impaired CI = Cognitively impaired LMI = Lower mobility impaired Disability Requirements

Telecommunication Device or Software

SGD Level 1 (SI and CI) or (SI and UMI) A hand-held device that generates digitized or synthesized speech using pictures. SGD Level 2 (SI and CI) or (SI and UMI) A device that generates digitized or synthesized speech using pictures that may allow for switch access. SGD Level 3 SI and UMI A device that generates digitized or synthesized speech using pictures that allows for eye control access. SGD Switch SI and UMI A device that connects to an SGD to allow the user to review and make selections. SGD Head Pointing or Movement Control Device SI and UMI A device that connects to an SGD to allow access to an SGD using head or other body movements. SGD Eye Control Access SI and UMI A device that connects to an SGD to allow access to an SGD using eye movements. SGD Mount (SI and LMI) or (SI and UMI) A device used to secure an SGD. SGD Switch Mount SI and UMI A device used to secure an SGD switch. SGD Moisture Guard (SI and CI) or (SI and UMI) A protective moisture barrier for an SGD device. SGD Key Guard (SI and CI) or (SI and UMI) A protective overlay that helps prevent inadvertent key activation. SGD Phone Compatible Attachment (SI and CI) or (SI and UMI) A device that enables an SGD to receive and make calls (including cords, cables, and kits). Infrared Telephone (SI and CI) or (SI and UMI) A phone that can be operated by infrared transmitted signals. Infrared Phone Switch (SI and CI) or (SI and UMI) A transmitting device that can be used to operate an infrared phone. SGD Wireless Card and Software (SI and CI) or (SI and UMI) A device that enables an SGD to make and receive calls through a wireless service. Anti-Stuttering Device SI and UMI Provides the user with Delayed Audio Feedback (DAF) and Frequency Shifted Audio Feedback (FAF). If an applicant is not certified as having an UMI, a voucher is issued at a lesser value. Speakerphone SI or UMI or CI A phone with a speaker built into the base.

DARS3907 (08/12) A+

Application for STAP Speech Generating Devices

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Step 4Provide a Professional Certification of Your Disability

A licensed speech-language pathologist must complete this section unless only anti-stuttering devices are requested (a DARS VR counselor may complete this form for anti-stuttering devices). Additional documents to supplement the pathologists response may be attached. Print clearly. Illegible information may be returned for clarification. Applicants name: Application number (for DHHS use only): 1. Specify manufacturer and product name of devices requested:

2. Accessories requested:

3. Describe the cause and severity of the applicants speech impairment.

4. Is the applicant reapplying for a voucher because of a change of disability? Yes No If yes, DARS3926, Change of Disability, must be completed. Contact [email protected] for this form or print it from the DHHS Web site at www.dars.state.tx.us/dhhs/dhhsforms.shtml. 5. Describe equipment and procedures used to establish the need for the requested equipment. Include the names of all devices that were tested during the evaluation even if they are not being requested.

Speech Generating Device Request If a speech generating device is requested, the certifier must complete questions 6 and 7. 6. Applicants ability (enter X to select all that apply). The person can:

press one button to communicate a thought.

combine single words to compose a message.

compose a message through spelling. compose a message through typing. other (describe):

use preprogrammed phrases to compose a message.

DARS3907 (08/12) A+

Application for STAP Speech Generating Devices

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7. In the following areas, describe any limitations experienced by the applicant that the need for the specific devices and accessories requested:

a) hearing status: b) vision status: c) cognitive status: d) upper mobility status: e) lower mobility status:

Certification

As the certifier, I attest to the following: I am eligible to certify under the provisions of STAP. The devices described are needed to provide the applicant with access to the telephone network. I have personally met with the applicant I am certifying and am aware of the extent of the applicants disability, which is consistent with the requirements of STAP. The applicants age or disability does not prevent the applicant from using the selected specialized devices to gain access to the telephone network. I understand that STAP may request additional documentation to confirm or supplement any information provided on the application, including physicians statements, medical records, or a copy of my license. All information I have provided on this application is valid and accurate to the best of my knowledge.

Printed name of certifier: Name of business: Street address: Telephone: () Fax: ()

SLP license number:

City: Email:

State:

ZIP code:

Signature of certifier (must be original, not a photocopy, facsimile, or stamp):

Date:

DARS3907 (08/12) A+

Application for STAP Speech Generating Devices

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