ADAPTIVE TELEPHONE EQUIPMENT LOAN PROGRAM

c/o Vocational Resources, Inc., 100 Houghton Street, Providence. RI 02940

Telephones (401) 276-0875 (Voice) (401) 861-6677 (TDD)

CERTIFICATE OF DISABILITY

To be completed by one of the following: a physician, an audiologist, a speech pathologist, a qualified staff member of the Office of Rehabilitation Services, or qualified member of the Rhode Island School for the Deaf.

Note to the professional: The above name applicant is seeking verification of his/her disability in order to qualify to receive an adaptive telephone device from the State of Rhode Island. Three disability groups are served: speech impaired, hearing impaired or deaf, neuromuscular impaired (anyone unable to dial or hold a receiver). If the applicant has full capability to use a standard telephone they could not qualify.

Thank you for your assistance.

IMPAIRMENT (S): (please circle one)

DEAF SPEECH IMPAIRED

HEARING IMPAIRED NON-VERBAL

BOTH DEAF & SIGHT IMPAIRED BOTH HEARING & SIGHT IMPAIRED

NEUROMUSCULAR DAMAGE OR DISEASE
(PLEASE SPECIFY BELOW I.E. MS, PARKINSONS, SEVERE ARTHRITIS ETC…)

__________________________________________________________________________________

Please give a brief description of the disability and how it affects your ability to use the telephone. ie: hearing impaired—would benefit with the use of an amplifier, aphasic—can understand telephone conversations but cannot speak; or neuromuscular disorder—cannot dial telephone, but can speak and hear conversations, etc.)
________________________________________________________________

I hereby certify that the above named individual has an impairment that restricts his/her use on a standard telephone. The information on this form is accurate and complete to the best of my knowledge. I understand that any attempt to provide fraudulent information will be prosecuted to the full extent of the law.

___Office stamp or label accepted___

Office or Agency Name_______________________________________________

Signature of professional______________________________________________

Address____________________________________________________________

Print name of Professional_____________________________________________

City______________ St_______________ zip___________

License #___________

DO NOT WRITE BELOW THIS LINE. FOR OFFICE USE ONLY

RETURN THIS FORM TO THE ABOVE ADDRESS