Division for Rehabilitation Services

Office for Deaf and Hard of Hearing Services

Application for Specialized Telecommunications
Assistance Program (STAP)
Speech Generating Devices
Step 1—Provide Applicant Information
Applicant’s first name:

Middle name:

Last name:

Street address (PO Box is not acceptable):

City:

State:

TX	ZIP code:

Home telephone number:

( )	Alternate telephone number:

( )	Social Security number:

TX driver’s license number:

Birth date:

Email:

Parent or legal guardian name:

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) Guardian or family member

Specify the person’s relationship to the applicant.
Signature. Unless the applicant signs the application or provides proof of residency in the applicant’s name, the same person must both sign the application and provide proof of residency. This application must have an original signature—not 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 physician’s statements or medical records.

All information given on this application is true.
Signature of applicant, parent, or legal guardian:

X	Printed name:

Date:

Mail to: STAP, PO Box 12607, Austin, TX 78711

This application form is valid until August 31, 2010

www.dars.state.tx.us/dhhs

Step 2—Provide Proof of Residency
Include a copy of one of the following as proof of your Texas residency:
Texas driver’s license

voter registration card	ID card with address	utility bill (showing address)

vehicle registration card	Medicaid ID

Medicare Summary
letter on the official letterhead of a residential facility signed by the director or supervisor
Proof of residency must name the applicant, parent, or legal guardian signing the application and show the home address.
Step 3—Select Device
You must meet the established disability requirements for the device requested. Note: these disability requirements are defined in the form instructions.
SI = Speech impaired	CI = Cognitively impaired
UMI = Upper mobility impaired	LMI = Lower mobility impaired
Telecommunication Device or Software	Disability Requirements
Enter X to select device needed:
ACD may include Augmentative Software	(SI and CI) or (SI and UMI)

Generates digitized or synthesized speech using pictures or text.
ACD Switch	SI and UMI

A device that connects to an ACD to allow the user to review and make selections.
ACD Head Pointing or Movement Control Device	SI and UMI

A device that connects to an ACD to allow access to an ACD using head or other body movements.
ACD Eye Control Access	SI and UMI

A device that connects to an ACD to allow access to an ACD using eye movements.
ACD Mount	(LMI and SI and CI) or (LMI and SI and UMI)

A device used to secure an ACD to a wheelchair.
ACD Switch Mount	(LMI and SI and CI) or (LMI and SI and UMI)

A device used to secure an ACD switch to a wheelchair.
ACD Moisture Guard	(SI and CI) or (SI and UMI)

A protective moisture barrier for an ACD device.
ACD Key Guard	(SI and CI) or (SI and UMI)

A protective overlay that helps prevent inadvertent key activation.
ACD Phone Compatible Attachment	(SI and CI) or (SI and UMI)

A device that enables an ACD to receive and make calls (including cords, cables, and kits).
Infrared Telephone	SI and UMI

A phone that can be operated by infrared transmitted signals.
Infrared Phone Switch	SI and UMI

A transmitting device that can be used to operate an infrared phone.
ACD Wireless Card and Software	(SI and CI) or (SI and UMI)

A device that enables an ACD to make and receive calls through a wireless service.
Anti-Stuttering Device	SI

Provides the user with Delayed Audio Feedback (DAF) and Frequency Shifted Audio Feedback (FAF).
Speakerphone	SI or UMI or CI

A phone with a speaker built into the base.
Step 4—Provide a Professional Certification of Your Disability
A licensed speech-language pathologist must complete this section. Additional documents to supplement the pathologist’s response may be attached. Print clearly. Illegible information may be returned for clarification.
Applicant’s name:

Application number (for DHHS use only):

1. Specify manufacturer and product name of device requested:

2. Accessories or additional items requested:

3. Is a mount for ACD necessary? Yes No	Mount for switch? Yes No
4. Describe the severity of the applicant’s speech impairment.

5. 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 stap@dars.state.tx.us for this form.
6. The applicant’s impairment is (enter X to select one):	Temporary	Stable	Progressive
7. 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.

Augmentative Communication Device Request (Optional)
If an augmentative communication device is requested, the certifier must complete questions 8–12.
8. Specify any limitations experienced by the applicant in the following areas:

a) hearing status:

b) vision status:

c) cognitive status:

d) upper mobility status:

e) lower mobility status:

Does the applicant become fatigued easily?	Yes	No
9. Applicant’s ability (enter X to select all that apply):

Person is able to press one button to communicate a thought.

Person is able to combine single words to compose a message.

Person is able to use preprogrammed phrases to compose a message.

Person is able to compose a message through spelling.

Person is able to compose a message through typing.

Other (describe)
10. What is the access method needed? (Enter X to select one.)

Keyboard	Finger Point	Head Point	Eye Movement

Switch	Mouse	Joystick

Other (describe access method used):
11. Describe the accuracy of applicant’s access method.	Good	Fair	Poor
12. List any other ACD features not already mentioned that the applicant requires in order to use the requested device because of existing disabilities.
Certification
As the certifier, I attest to the following:

I am eligible to certify under the provisions of STAP.

The device selected on this form is 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 applicant’s disability, which is consistent with the requirements of STAP.

The applicant’s 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 as needed to confirm or	supplement any information provided on the application, including physician’s 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:

SLP license number:

Name of business:

Street address:

City:

State:

ZIP code:

Telephone:

( )	Fax:

( )	Email:

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

X	Date:

DARS3907 (09/09)	Application for (STAP) Speech Generating Devices	Page 4 of 4

DARS3907 (09/09)
Page 1 of 4

DARS3907, DHHS Application for Specialized Telecommunications Assistance Program (STAP): Speech Generating Devices and/or Special Requests

DARS

2009-08-18

Jola Edwards