Please return application to:
Center for Rehabilitation Engineering
UMASS Dartmouth, 285 Old Westport Rd., N. Dartmouth, MA 02747
Telephone: (508) 999-8482 or Fax: (508) 999-8489
www.share.umassd.edu
Attn: Client Services Coordinator
Equipment Loan/Services Application
(total of 4 pages)
Applicant information:
Name:
Age:
Address:
Nature of Disability:
Phone (H):
Best time to call:
Phone (C):
Best time to call:
Phone (W):
Best time to call:
D.O.B.
E-mail address:
In addition to the applicant, who should we contact regarding this application?
Name:
Home phone:
Relationship to applicant:
Cell phone:
Email address:
How did you learn about us?
Agency referred by:
Phone and extension:
Contact name:
Title:
Email address:
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Please feel free to use additional paper if needed.
Give a brief description of your disability.
How does your disability impact on your daily life?
Please describe the system/services you are seeking.
How would a computer system/adaptive equipment/services help you? What do you
expect it to enable you to do?
Have you used computers/adaptive equipment in the past? If yes, what kind of system
have you used?
Would your disability affect how you would use a computer/adaptive equipment?
If so, explain what special adaptations may be required.
Do you now own a system?
If so, please provide the system information.
Make and model #:________________________________________________________
Operating system:____________________
Answer yes/no for the following questions
32 bit –yes /no / unknown
_____ phone dialup modem
64 bit – yes / no / unknown
_____ DSL modem
Processing speed (MHz):______________
_____cable modem/NIC
Memory (RAM):_____________________
_____CD / DVD ROM/DVR
Hard drive space:_____________________
_____Sound Card
Free disk space:______________________
_____Speakers
Other (printer, scanner, etc.)________________________
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We are sometimes aware of local vendors who have rebuilt or refurbished equipment
available at reasonable prices. Are you interested in purchasing equipment if we do not
have what you want available for loan?
Do you require a computer system: yes or no (circle one)
Do you require internet access? If yes:
DSL or cable. (circle one)
Do you require sound card and speakers?
Where is the system to be used? Home, school, work, community. (circle one)
Who will provide training and support for simple day to day difficulties?
***Except for our own programs, we do not provide software. Additionally, we cannot guarantee
all software will run on the computer issued.
that
to
Other
Speaker
***Please attach separate paper if more software
is to be installed.
Company Name / Software Title
1.
Sound Card
System Requirements
(found on the side of the box)
Operating
System
Processing
Speed-MHz
Memory
(RAM)
Free disk
space
CD
***Please include the names and system requirements for any commercial software that you intend
install in the system.
Who will provide it?
2.
3.
4.
5.
6.
7.
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This section is used when we search out grants. Does NOT disqualify applicant.
Please initial to indicate response. Do you receive any of the following:
Yes No
___ ___ Supplemental security income. (SSI).
___ ___ Emergency aid to the elderly, disabled, and children(EAEDC) (M.G.L.C118A)
___ ___ Emergency assistance. (M.G.L. C117)
___ ___ Transitional aid to families with dependent children(TAFDC) (M.G.L.C118)
Ethnicity:
____________________________________Other (O) ______
_____American Indian/Alaska Native (A)
Hispanic/Latino (H)_____
_____Asian (AS)
White: Non-Hispanic/ Non-Latino (W) _____
_____Black or African American (B)
Choose not to answer (X) _____
_____Native Hawaiian/Other Pacific Islander (N)
HOUSEHOLD SIZE – equal or under this INCOME LEVEL (please initial one)):
____ 1 person - up to $64,250
____ 4 -- $91,800
_____ 7 -- $113,850
____ 2 people -- $73,450
____ 5 -- $99,150
_____ 8 -- $121,200 or more
____ 3 -- $82,600
____ 6 -- $106,500
_____ does not fit any of these categories
Do you qualify for service through a service provider? If so, please specify contact
information ( contact name, telephone number, email address ).
*Are you a Veteran?
YES
NO
Medicaid:_______________________________________________________________
_____________________________________
State Commission for the Blind:_____________________________________________
______________________________________
Dept. of Developmental Services:___________________________________________
______________________________________
Department of Mental Health:_______________________________________________
Do you receive service through the Massachusetts Rehabilitation Commission?
If so, is it through the vocational rehabilitation or independent living division?
Who is your MRC contact person and what is their telephone number?
Can you, a family member, or a friend arrange to pick up the equipment at UMass
Dartmouth during normal working hours?
Monday-Thursday: 9am-5pm
Friday: 9am-12pm
__________________________________________
Signature
08/2014
____________________________
Date
4