Before you submit your application for a speech generating device, we encourage you to take the following steps:

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1 Public Utility Commissio Residetial Service Protectio Fud Telephoe Assistace Programs 201 High St SE Suite 100 Salem, OR Mailig Address: PO Box 1088 Salem, OR TTY: Fax: Web: Dear Applicat, Thak you for your iterest i obtaiig a speech geeratig device (SGD) from the Telecommuicatio Devices Access Program (TDAP). Our goal is to loa these devices to eligible customers who have a severe or greater speech impairmet. Due to a cap o fudig, we will provide SGDs o a first come, first served basis. Before you submit your applicatio for a speech geeratig device, we ecourage you to take the followig steps: Explore the possibility of obtaiig a SGD through private isurace, Medicaid or Medicare, Work with your America Speech-Laguage-Hearig Associatio (ASHA) certified speechlaguage pathologist (SLP) i selectig the SGD that best meets your eeds ad Cotact the maufacturers or vedors for assistace i selectig a SGD. (See page 1 of the eclosed applicatio.) Please complete ad sig Sectio A o page 2 ad 3 of the applicatio. Make sure your SLP completes ad sigs Sectio B o page 4 ad 5. We look forward to workig with you. If you have ay questios or cocers, please cotact us usig ay of the methods listed above Moday through Friday, 9 a.m. to 4 p.m. Sicerely, TDAP Staff

2 Orego Telecommuicatio Devices Access Program (TDAP) Speech Geeratig Devices Applicatio AVAILABLE SPEECH GENERATING DEVICES Vedor Speech Geeratig Device Access Methods Pretke-Romich Accet 800 Accet 1000 Accet 1400 PRio PRio Mii NuEye NuPoit Teltex ipad ipad Mii ipad Pro (10.5 ) ipad Pro (12.9 ) N/A Tobii-Dyavox T-7 I-12 I-15 I-110 Idi EyeMobile Mii PC Eye Mii PC Eye Explorer Saltillo Nova Chat 5 Plus Nova Chat 8 Plus Nova Chat 10 Plus Nova Chat 12 Plus Chat Fusio 10 Plus ChatPoit Smartbox Grid Pad Go 8 Grid Pad Go 10 Grid Pad Pro 12 w/ Mout plate Eyegaze - Irisbod Duo Eye Trackig Camera Please cotact the maufacturer for assistace i selectig a speech geeratig device. VENDOR CONTACT INFORMATION VENDOR PHONE NUMBER ADDRESS WEB SITE Pretke-Romich service@pretrom.com Teltex ifo@teltex.com Tobii-DyaVox css@tobiidyavox.com Saltillo ifo@saltillo.com Smartbox ifo@thiksmartbox.com PAGE 1

3 Speech Geeratig Devices Applicatio Orego Public Utility Commissio PO Box 1088, Salem, OR or TTY: VP: Fax: or SECTION A Orego Telecommuicatio Devices Access Program (TDAP) Please Prit Your Iformatio ad Sig o Page 3 ( Required Iformatio ) Please ote you may be able to acquire a speech geeratig device through private isurace, Medicaid or Medicare. TDAP loas speech geeratig devices for phoe access to eligible Oregoias who may otherwise be uable to obtai a speech geeratig device. ( ) ( ) Name of Applicat (Last, First, Middle) Phoe/Cell Other phoe Home Address Apt. # City ZIP Couty Paret/Guardia Name (If applicat is a mior) Mailig Address (If differet tha above) Apt. # City ZIP Applicat (or Paret/Guardia) Applicat Date of Birth Orego Drivers Licese or ID # (If you do ot have a ODL or ID #, please cotact TDAP) Address Alterate Cotact Name (Last, First) Relatioship (e.g. spouse, fried, relative, or caregiver) ( ) Phoe/Cell Mailig Address of Cotact Perso Apt. # City ZIP I authorize my certifyig speech-laguage pathologist to release all appropriate ad ecessary medical iformatio required for the sole purpose of selectig the most appropriate goods or services provided by the Orego TDAP. Yes q No q PAGE 2

4 Coditios of Acceptace ad Agreemet for TDAP Speech Geeratig Devices Please READ ad SIGN the form that idicates you uderstad ad agree to comply with the followig coditios upo acceptace of all TDAP Speech Geeratig Devices (Equipmet): All Equipmet is the property of the State of Orego ad I will use it i compliace with Orego laws ad regulatios, icludig Orego Admiistrative Rule Chapter 860 Divisio 033. I will ot offer for sale, sell, give away, or loa ay Equipmet to ayoe. I am fiacially resposible for ay damage to ay Equipmet that is ot caused by ormal wear ad tear or acts of ature or disaster. [Note: A price list of the most curret prices for previously used ad curret Equipmet is available upo request.] I am resposible for the appropriate care of all Equipmet ad will use it for accessig telephoe ad related services. I will ot remove the protective case from the Equipmet. I will ot damage or deface the Equipmet (e.g., removig ay property of Orego idetifyig labels, alterig the laser etchig, etc.). I uderstad that the Equipmet may have a web filter istalled to prohibit access to websites cotaiig ulawful, adult or iappropriate cotet. The TDAP office ad TDAP Vedors have my permissio to moitor the Equipmet to esure proper use. I will retur defective or damaged Equipmet at the PUC s expese. The PUC will repair or replace the retured Equipmet at its discretio. If ay Equipmet is stole, I will otify the local law eforcemet agecy withi 24 hours of the time the theft is discovered. I will provide a copy of the police report to the TDAP office withi five (5) busiess days of the date that I reported the theft. If floods, storms, fire, or other acts of ature damage the Equipmet, I will submit a fire departmet, isurace, police or other appropriate report about the evet to the TDAP office withi five (5) busiess days after the date the evet occurred. If I move to aother place i Orego, I will report my ew address to the TDAP office withi thirty (30) caledar days of the move. I am resposible for the purchase of Equipmet supplies, such as headphoes, ad the costs related to the use of the Equipmet, such as Wi-Fi service. I will retur all Equipmet to the TDAP office before I permaetly move out of Orego. I am liable for the replacemet cost of ay Equipmet I fail to retur before movig out of Orego. I will obtai writte permissio from PUC s TDAP Maager before I travel out of the State of Orego with ay Equipmet for more tha 90 days. If I have siged this Agreemet o behalf of a mior or as a guardia for a adult, I will otify the TDAP office about a chage i resposibility withi five (5) caledar days of the evet (for example, the mior reaches 18 or there is a chage of guardia). I uderstad that TDAP will bill me for ay Equipmet if the mior does ot sig a ew Coditio of Acceptace ad Agreemet withi 30 caledar days after the mior s 18th birthday ad I am resposible for payig that bill. I uderstad that all Equipmet is provided o a first come, first served basis ad its availability is cotiget upo adequate fudig. All statemets I have made i this applicatio are true ad correct to the best of my kowledge. Sigature of Applicat or Paret / Guardia (If Applicat is uder 18) Date *Please provide a copy of the Power of Attorey/guardiaship documetatio if sigig o behalf of applicat. PAGE 3

5 SECTION B PROFESSIONAL CERTIFICATION FORM This sectio is ONLY to be completed by a ASHA certified speech-laguage pathologist. o Hard of Hearig/Deaf o Mild o Moderate o Severe o Profoud IMPAIRMENT (CHECK ALL THAT APPLY) o Speech o Moderate o Severe o No Usable Speech o Laguage o Expressive o Receptive o Both Other Impairmets - For TDAP Iformatio Purposes Oly o Mobility o Upper o Lower o Both o Cogitive o Mild o Moderate o Severe/Profoud SPEECH GENERATING DEVICE REQUEST Primary Device Requested: Access Method (if eeded): Secodary Device Requested: Access Method (if eeded): SPEECH APP SELECTION (FOR IPADS ONLY) If selectig a ipad, please provide the ame of the speech app below ad provide a justificatio for this request as a amedmet to this applicatio. App Name: Please cotiue to page 5 PAGE 4

6 SECTION B CONTINUED PROFESSIONAL CERTIFICATION FORM Please provide the followig iformatio i detail as a amedmet to the applicatio: I. Applicat s commuicatio abilities: a. Ability to commuicate without use of a device b. Previous experiece with devices (if applicable) c. Why are previously owed or issued devices o loger beig used (if applicable) d. Applicat s curret meas of commuicatio II. Selectio of device: a. List all devices cosidered ad ratioale for elimiatio b. Ratioale for selectio of specific device c. Idicatios for success with selected device d. Describe the applicat s experiece usig the selected device (if applicable) e. Ratioale for selectio of a alterate (secodary) device f. Idicatios for success with alterate (secodary) device g. Describe the applicat s experiece usig the alterate (secodary) device (if applicable) III. Usig the device: a. Expectatios for applicat s commuicatio ability while usig the device b. Perceived duratio of eed to use the device c. Plas for successful phoe commuicatio usig the device d. Speech-Laguage Pathologist s cotiuig plas to assist the applicat i usig the device e. Support ecessary for applicat to be successful usig the device (e.g. caregiver, family members, other professioals) Required: I hereby certify that (Applicat s Name Last, First) requires the use of a speech geeratig device to commuicate effectively o the phoe. ASHA CERTIFIED SPEECH LANGUAGE PATHOLOGIST Name (Prit or Type) Title ASHA Licese Number Street City State ZIP ( ) Phoe ( ) Fax Address Sigature Date PAGE 5