Fillable CITY OF PRIEST RIVER COMMUNICATION ASSESSMENT FORM (City of Priest River)

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CITY OF PRIEST RIVER COMMUNICATION ASSESSMENT FORM (City of Priest River)

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CITY OF PRIEST RIVER
COMMUNICATION ASSESSMENT FORM
Date of Request: ________________
Staff Person Conducting Assessment: ______________________________
1. Contact information of person requesting auxiliary aids or services:
Name: ___________________________________________________________
Phone: ___________________ Email: _________________________________
2. Describe the program, service, or activity you plan to attend: _________________
________________________________________________________________
________________________________________________________________
3. Date of activity: ____________ Time of Activity: __________________________
4. Location of activity: _________________________________________________
5. What is the nature of your disability that requires auxiliary aids or services?
□ Deaf
□ Hard of Hearing
□ Disability
□ Blind
□ Visually Impaired
□ Other: ______________
6. Relationship:
□ Self
□ Family Member
□ Friend/Companion
□ Other: ______________
7. Please check one of the boxes below next to your choice of Interpreter Services.
If your preferred service is not listed, please identify and describe.
□ American Sign Language (ASL) Interpreter
□ Pidgin Signed English (PSE) Interpreter
□ Signed English Interpreter
□ Video Interpreting Services (VIS)
□ Oral Translators
□ Qualified Reader
□ Cued Language Translators
□ Other. Describe: _________________________________________________
8. Please check one or more of the boxes below if you are requesting any of the
following auxiliary aids or services for effective communication. If your preferred
aid or service is not listed, please identify and explain.
□ TTY/TTD (text telephone)
□ Video Relay Services (VRS)
□ Assistive Listening Device (sound amplifier)
□ Qualified note-takers
□ Writing Back and Forth
□ CART: Computer-assisted Real Time Transcription Service
□ Other. Describe: _________________________________________________
We are requesting your information so you can participate in our programs, services, or
activities. All communication aids and services are provided FREE OF CHARGE. If you
need further assistance, please contact Laurel Thomas. If you have any questions please
call our office at 208-448-2123 (voice), email at lthomas@priestriver-id.gov, or visit us
during business hours.
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CITY OF PRIEST RIVER COMMUNICATION ASSESSMENT FORM (City of Priest River)

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Completed 14 July 2020

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