ATTACHMENT A: COMMUNICATION ASSESSMENT FORM
am/pm
Date Time
Name of Person with Disability
Patient's Name (if not person with disability)
Nature of Disability:
❏ Deaf
❏ Hard of Hearing
❏ Speech Disability
❏ Other: ______________
Relationship to Patient:
❏ Self
❏ Family Member
❏ Friend / Companion
❏ Other: _____________
Do you want a professional sign language or oral interpreter for your visit?
❏ No. I do not use sign language and do not use interpreters to lip read.
❏ No. I prefer to have family members/ friends help with communication.
❏ No. I do not feel an interpreter is necessary or do not want one for this visit.
❏ Yes. Choose one (free of charge):
❏ American Sign Language (ASL) interpreter
❏ Pidgin Signed English (PSE) interpreter
❏ Signed English interpreter
❏ Oral interpreter
❏ Other. Explain: _____________________________
Which of these would be helpful for you for effective communication? (free of charge)
❏ TTY/TDD (text telephone)
❏ Assistive listening device (sound amplifier)
❏ Qualified note-takers
❏ Writing back and forth
❏ CART: Computer-assisted Real Time Transcription Service
❏ Other. Explain: _________________________________________
We ask this information so we can communicate with you effectively. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask a member of our office staff.
Any questions? Please call our office, ______________(voice), ______________ (TTY), or visit us during normal business hours.
ATTACHMENT B
Center for Orthopaedic and Sports Medicine, Inc. (“The Center”) and its office staff are committed to providing equal access to patients, family members, and companions with disabilities.
To ensure effective communication, The Center provides qualified sign language and oral interpreters, and other auxiliary aids and services free of charge for patients, family members, and companions who are deaf, are hard of hearing, or have speech disabilities.
To request auxiliary aids or services, please speak to ______________. If an auxiliary aid or service is denied, you can request a reconsideration by providing this office with a written statement explaining why you need the aid or service that was denied. If needed, office staff can help write down your request for reconsideration. If you have any problems, please speak to _________________ directly.
The Americans with Disabilities Act (ADA) prohibits discrimination against people with disabilities. People who are deaf, are hard of hearing, or have speech disabilities have the right under the ADA to request auxiliary aids and services. For more information about the ADA, call the Department of Justice’s toll-free ADA Information Line at 1-800-514-0301 (voice), 1-833-610-1264 (TTY) or visit the ADA Home Page at archive.ada.gov