Fillable DEVICE LOAN REQUEST FORM

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DEVICE LOAN REQUEST FORM

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The DEVICE LOAN REQUEST FORM form is 5 pages long and contains:

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Illinois Assistive Technology Program
DEVICE LOAN REQUEST FORM
Name
1. COMPLETE THE FOLLOWING FOR THE PERSON REQUESTING THE EQUIPMENT
Phone Number Alt. Phone Number
TWO PHONE NUMBERS MUST BE PROVIDED
Street Address
Place of Employment
City/State/Zip County
Fax E-Mail
Type of individual or Entity Requesting Equipment (please select only ONE response which best describes the
capacity in which you are requesting equipment.
Individual with a disability
Family member, guardian or authorized representative
Educational Organization
Employer or Business
Provider of Employment and/or Training Services
Health, allied health, rehabilitation organization
Information Technology Professional
The primary purpose for which I need (or the person I represent needs) an AT device or service is related to
Education - participating in any type of educational program (if checking education, please include the
following)
Grade Level (select one)
Elementary
Middle
High School
Location of Use (select one)
General education setting
Home
Multiple setting
Purpose of Device (select one)
Access / Participate in general education
Access / Participate in community or vocation program
Access / Participation social working
Other
Specify
ISBE Referral Number(if applicable):
School Name
School Address
Zip
School Information
Community Living - carrying out daily activities, participating in community activities, using
community services, or living independently.
Employment - finding or keeping a job, getting a better job, or participating in an employment training
program, vocational rehabilitation program, or other program related to employment.
Information Technology / Telecommunications - using computers, software, web sites,
telephones, office equipment, and media.
Please Indicate if you are receiving or have received services from any divisions of the Illinois Department of
Human Services.
Division of Human Capital Development Services
Cash Assistance
Food Stamp
Medical Assistance Card
Division of Developmental Disabilities Services
Early Intervention
Day Services
In-Home Support
CILA
Group Home
ICF-DD Nursing Home
Other
Specify
Division of Rehabilitation Services
Home Services Program
Vocational Rehabilitation Services
ICRE-Wood Blind / Visually Impaired Residential Program
Blind / Visually Impaired Rehabilitation
Older Blind Services
School for the Deaf or Visually Impaired, or ICRE-Roosevelt
Other
Specify
Division of Mental Health Services
Community - Based Mental Health Services
Other
Specify
Do you borrow assistive technology equipment from another source?
Yes No
If Yes please specify from where:
Specify
2. Complete this section for the person who will be using the equipment
Age
0 - 5 6 - 21 22- 65 65 +
Disability
Race \ Ethnicity
African - American Asian Caucasian Latino
Other
3. Equipment Requested
Name of Item
Name of Item
Name of Item
Name of Item
Please check here if manuals ARE NOT required with equipment requested.
4. Primary Purpose (please select only one response which best describes the purpose in which
you are requesting the equipment)
Assist in decision making (device trial or evaluation)
Serve as loaner during device repair or while waiting for funding
Provide an accommodation on a short - term basis
Other
Specify
5. Address for delivery where someone is available Monday thru Friday, 9am to 5pm. Do not use
a P.O. Box number for shipping address, you must include a street reference. If delivery is at a
large facility you must specify department and / or room number.
If this address is the same as the person requesting the equipment check here and go to
section 6.
Name Phone Number
Organization\Agency
Department
Street Address Apartment / Room #
City/State/Zip
Are you Medicaid eligible?
Yes No
In the event of a theft of the device(s), component(s) or accessory(ies), I/We shall not be responsible
therefore if I/We immediately report the theft to the local law enforcement agency and provide a copy of
that report to the Illinois Assistive Technology Program.
6. Please read and sign BOTH the Borrower's Responsibility and Liability and the Release of
Liability Statements. The person who is the responsible party for this loan should sign these
statements.
BORROWER'S RESPONSIBILITY AND LIABILITY
I/We understand and agree that I/We am/are responsible for the proper handling, storage, use, care,
maintenance and return of the device(s)., component(s) or accessory(ies) loaned to me/us hereunder.
I/We shall pay all costs for shipping and return of all device(s), component(s) or accessory(ies) to the
Illinois Assistive Technology Program on or before the due date indicated herein or upon written demand
for the same.
In the event that I/We lose the device(s), component(s) or accessory(ies), I/We shall be liable for the
current replacement value thereof. Further, I/We shall immediately contact Illinois Assistive Technology
Program at 1-800-852-5110V/TTY to report such loss.
In the event that the device(s), component(s) or accessory(ies) thereto malfunction, I/We shall
immediately notify the Illinois Assistive Technology Program at 1-800-852-5110 V/TTY.
I/We may be required to provide collateral or other security to the Illinois Assistive Technology Program
for securing my/our obligations hereunder. I/We shall be responsible for any and all damages or
diminution in value of the device(s), component(s) and accessory(ies) beyond normal wear and tear to be
determined in the sole discretion of the IllinoisAssistive Technology Program.
I/We shall also remit to Illinois Assistive Technology Program any and all insurance proceeds representing
the value of any device(s), component(s) or accessory(ies) thereto provided by insurance policies covering
my/our residence or its contents, including but not limited to homeowner's or renter's insurance.
I/We shall not pledge, assign, transfer or otherwise give any interest in and to the devices(s), component(s)
and accessory(ies) to any third party. Illinois Assistive Technology Program shall recieve and I/We shall pay
and be responsible for any and all costs associated with return of the device(s), component(s) and
accessory(ies), including but not limited to costs and fees of litigation, reasonable attorney's fees and
costs, repossession costs and any other costs reasonably incurred by the Illinois Assistive Technology
Program.
Venue shall lie in the Seventh Judicial Circuit, Sangamon County, Illinois, for any and all litigation regarding
thedevice(s), component(s) or accessory(ies).
I/We understand it is illegal to copy or distribute any proprietary software or hardware loaned through the
Illinois Assistive Technology Program. Upon completion of the loan, if I/We have installed such software on
my/our computer, I/We shall remove said software.
In the sole discretion of the Illinois Assistive Technology Program, my/our ability to further participate in any
such programs or grants or loans from the Illinois Assistive Technology Program and all of its related
programs may be suspended for a period of time or indefinitely for failure to abide by the Loan Request Form
and all of its obligations,including but not limited to, failure to return the device(s), component(s) or
accessory(ies) in a timely manner; failure to pay for any and all costs or fees which are the responsibility of
the borrower(s); and the return of any devices(s), component(s) or accessory(ies) in a condition beyond
normal wear and tear.
Date
Signature of Borrower
Signature of Borrower Date
I agree to indemnify and hold harmless the Illinois Assistive Technology Program and any and all employees,
agent or representatives of same, from damages to property or injuries (including death) to myself, and/or
any other person, and any other losses, damages, expenses, claims, demands, suits, and actions by any
party against the Illinois Assistive Technology Program and any and all employees, agent or representatives
of same, in connection with loan(s) from the Illinois Assistive Technology Program.
Signature of Borrower Date
Return your completed, SIGNED request form to Illinois Assistive Technology Program, Attention:
Nikki Schultz, 1020 South Spring Street, Springfield, Illinois 62704
RELEASE OF LIABILITY
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DEVICE LOAN REQUEST FORM

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Completed 3 March 2021

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