Loaner Communication Device Application

To apply for assistance, please complete the following:

First Name

Last Name

Phone Number

Street Address

City

State

Zip Code

Florida county of residence:

Is the person with ALS a U.S. military veteran?

Name, phone number, and email for the family member/caregiver who will assist the person with ALS in the use of the communication loaner equipment:

Name, phone number, and email for the Power of Attorney (POA) or the person who will be designated as POA for the person with ALS:

The person with ALS is currently receiving the following:

Speech TherapyOccupational TherapyPhysical TherapyRespiratory TherapyIs not currently receiving therapy

Name and contact information for your Speech and Language Therapist, Assistive Technologist, Occupational Therapist or health care professional assisting with the application:

Please check the statement that applies to you:

Please provide contact information for the hospice, nursing home or hospital:

Please describe the insurance coverage the person with ALS currently holds: (Please select all that apply) Please make at least 1 selection from the choices below.:

PrimarySecondaryAdditionalUninsured

Has a communication device been ordered through a physician's order to be covered by Medicare, Medicaid or private insurance?

Enter the Name/Model of the communication device approved and ordered through insurance company: (e.g. Tobii Dynavox I-15)

Is the person with ALS using a computer or a dedicated communication device now (e.g., a tablet, a smart phone, a boogie board, etc.)?

Does the person with ALS have visual impairments?

Does the person with ALS have hearing impairments?

The language spoken by the person with ALS is:
Please make up to 4 selections from the choices below.

EnglishSpanishCreoleOther

How experienced is the person with ALS with computers?
Please make up to 4 selections from the choices below.

Very experienced with computersSomewhat experienced with computersNot experienced with computersNot experienced with computersI am not requesting a loaner or exchange computer.

Subscribe to receive communications

Advocacy	Corporate partnerships	Fundraising
Events	Care services	Administrative

Rate the status of the upper limbs of the person with ALS:
Please make 2 selections from the choices below.

Left Arm/Hand goodLeft Arm/Hand fairLeft Arm/Hand poorLeft Arm/Hand no controlRight Arm/Hand goodRight Arm/Hand fairRight Arm/Hand poorRight Arm/Hand no control

Rate the status of the upper limbs of the person with ALS:
Please make 2 selections from the choices below.

Left Leg/Foot goodLeft Leg/Foot fairLeft Leg/Foot poorLeft Leg/Foot no controlRight Leg/Foot goodRight Leg/Foot fairRight Leg/Foot poorRight Leg/Foot no control

Describe the part of the body that the person with ALS has the most control of:

Describe the mobility status of the person with ALS:
Please make between 1 and 7 selections from the choices below.

Walk IndependentlyUnsteady GaitAided with CaneAided with WalkerUse Manual Wheelchair IndependentlyUse Manual Wheelchair with AssistanceUse Power Wheelchair

Rate the head control of the person with ALS:
Please make 1 selection from the choices below.

GoodFairPoorNo control

Rate the upper body strength of the person with ALS:
Please make 1 selection from the choices below.

GoodFairPoorNo control

Based on your professional opinion, please select all that apply when describing the patient's pitch:
Please make at least 1 selection from the choices below.

WNLMonopitchLow pitchVoice TremorPitch BreaksDiplophonia

Based on your professional opinion, please select all that apply when describing the patient's prosody:
Please make at least 1 selection from the choices below.

WNLSlow RateShort PhrasesProlonged IntervalsExcess & Equal StressInappropriate SilencesVariable RateShort Rushes of SpeechRapid Rate

Based on your professional opinion, please select all that apply when describing the patient's resonance:
Please make at least 1 selection from the choices below.

WNL Hypernasality Nasal Emission Hyponasality Variable Nasality Weak Pressure Consonants

Based on your professional opinion, please select all that apply when describing the patient's loudness:
Please make at least 1 selection from the choices below.

WNLHypophonicMonoloudnessLoudness DecayLoudness Control Problem

Based on your professional opinion, please select all that apply when describing the patient's articulation:
Please make at least 1 selection from the choices below.

WNLAnarthricDistorted VowelsImprecise ConsonantsIrregular Articulatory BreakdownProlonged PhonemesRepeated Phonemes

Based on your professional opinion, please select all that apply when describing the patient's vocal quality:
Please make at least 1 selection from the choices below.

WNLAphonicHarshStrained-StrangledBreathy (Transient)Breathy (Continuous)Hoarse

Based on your professional opinion, please select all that apply when describing the patient's respiration:
Please make at least 1 selection from the choices below.

WNLRestrictedForced InspirationAudible InspirationInhalatory StridorGrunt at End of Expiration

Based on your professional opinion, please select all that apply when describing the patient's diadochokinetic performance:
Please make at least 1 selection from the choices below.

WNLFast RAMs/DDKDeferredSlow RAMs/DDKIrregular RAMs/DDK

In your professional opinion, what is the patient's speech intelligibility percentage?

If known, what is the patient's forced vital capacity (FVC)?

Based on your professional opinion, what access method would best fit the needs of the person with ALS?

Based on your professional opinion, what communication method would best fit the needs of the person with ALS?

What are some communication goals for the patient (e.g., composing emails, asking questions at clinic, using SGD in conjunction with Skype, having a low-tech back up for communication, etc.)?

If there is a concern or issue this survey did not address that, in your professional opinion, would help the selection process or that The ALS Association should know, please use the answer box below to leave your comments. Please feel free to describe additional information that would help us fulfill the AAC request (e.g., language ability). Thank you.

Name of person completing and submitting this application:

Phone number of person completing this application:

PLEASE NOTE: This application must be filled out by a health care professional. Any information provided in this survey will NOT be submitted to a third party (i.e., insurance company) or be entered into a medical record. Health care providers, please answer questions to the best of your ability. We greatly appreciate your time and effort.

Release of Information and Assumption of Risk, Waiver and Release of Liability, and Indemnification Agreement

I authorize the ALS Association to communicate with, obtain information from, and provide information to any service provider, including medical providers and insurance companies, for the purpose of discussing or arranging the services I request or need regarding the program.

In consideration of the ALS Association furnishing, discounts and grants for equipment or ALS medically related expenses and services prescribed or recommended by an ALS health care professional, as part of my participation in the program, I agree as follows:

ASSUMPTION OF RISK - I understand that my participation in the program contemplates the receipt of discounts and grants from the ALS Association that may be used for, but is not limited to, my receipt of services, use of equipment, or operation of a vehicle. I understand and acknowledge that: (a) risks and dangers exist in my receipt of services, use of equipment, or operation of a vehicle that derive from the discounts and grants provided to me by the ALS Association; (b) my receipt of services, use of equipment, or operation of a vehicle that derive from the discounts and grants provided to me by the ALS Association may result in injury or death either to me or a third party; (c) these risks and dangers may be caused by the actions, inaction or negligence of either me or a third party; and (d) there may be risks not known to me or not reasonably foreseeable.

WAIVER AND RELEASE OF LIABILITY - I forever release, discharge and acquit the ALS Association from any and all claims, demands, suits, or causes of action of any nature which I may have against the ALS Association for damages, costs, expenses, attorneys' fees, damages to or loss of property, or personal injury, or death or any other losses or damages whatsoever that arise out of any act, occurrence, or accident in any way connected with my participation in the program.

INDEMNIFICATION - I agree to defend, indemnify and hold harmless the ALS Association from and against any claims, demands, suits, or causes of action of any nature by any third party for damages, costs, expenses, attorneys' fees, damages to or loss of property, or personal injury, or death or any other losses or damages whatsoever that arise out of any act, occurrence, or accident in any way connected with my participation in the program.

MISCELLANEOUS -

I agree that this Agreement shall be interpreted and enforced in accordance with Florida law.
I agree that if one or more paragraph(s) of this Agreement are ruled invalid or unenforceable, such invalidity or unenforceability
shall not affect any other provision of the Agreement, which shall remain in full force and effect.
I agree that each provision of this Agreement is intended to be severable. If any term or provision of this Agreement is illegal or invalid for any reason whatsoever, such illegality or invalidity shall not affect the validity or legality of the remainder of this Agreement.
As used in this Agreement, I understand the term “I,” "me," or "my" shall include my heirs, personal representatives, assigns, and agents. I understand that this Agreement binds my heirs, personal representatives, assigns, and agents.
As used in this Agreement, I understand the term “the ALS Association” shall mean the ALS Association, as well as the ALS Association's officers, trustees, employees, volunteers, agents, representatives, and affiliated organizations.
As used in this Agreement, I understand that the singular shall include the plural and vice versa; the terms “and” and “or” shall be both conjunctive and disjunctive; and the term “including” means “including without limitation.

I have read the above and fully understand 1.) The purpose, procedures, requirements, and 2.) This assumption of risk, waiver and release of liability, and indemnification agreement. I understand that I am giving up substantial rights, including my right to sue the ALS Association, and its officers, trustees, employees, volunteers, agents, representatives, and affiliated organizations. I also understand that this agreement binds heirs, my personal representatives, assigns, agents, and me. I acknowledge that I am signing this agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of liability. I assert that my participation in the care assist program is voluntary and I knowingly assume all such risks.

By selecting "YES", I am agreeing to the above Release of Information, Assumption of Risk, Waiver and Release of Liability, Indemnification Agreement and general terms of the grant program.

Yes

This form is an application, not a survey. By clicking on the Submit button, you are applying for Communication Equipment Assistance and your application is being sent to The ALS Association.

For more information, please contact infoFL@als.org.

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