Dear Applicant,
Thank you for your interest in obtaining a speech generating device (SGD) from the
Telecommunication Devices Access Program (TDAP). Our goal is to loan these devices to eligible
customers who have a severe or greater speech impairment. Due to a cap on funding, we will
provide SGDs on a “rst come, rst served” basis.
Before you submit your application for a speech generating device, we encourage you to take the
following steps:
Explore the possibility of obtaining a SGD through private insurance, Medicaid or Medicare,
WorkwithyourAmericanSpeech-Language-HearingAssociation(ASHA)certiedspeech-
language pathologist (SLP) in selecting the SGD that best meets your needs and
Contact the manufacturers or vendors for assistance in selecting a SGD. (See page 1 of the
enclosed application.)
Please complete and sign Section A on page 2 and 3 of the application. Make sure your SLP
completes and signs Section B on page 4 and 5. We look forward to working with you.
If you have any questions or concerns, please contact us using any of the methods listed above
Monday through Friday, 9 a.m. to 4 p.m.
Sincerely,
TDAP Staff
Public Utility Commission
Residential Service Protection Fund
Telephone Assistance Programs
201 High St SE Suite 100
Salem, OR 97301-3612
Mailing Address: PO Box 1088
Salem, OR 97308-1088
1-800-848-4442
TTY: 1-800-648-3458
Fax: 1-877-567-1977
Web: www.rspf.org
Email: puc.rspf@state.or.us
FM608SGD (Revised 01/22/2020)
AVAILABLE SPEECH GENERATING DEVICES
Oregon Telecommunication Devices Access Program (TDAP)
Speech Generating Devices Application
PAGE 1
Vendor Speech Generating Device Access Methods
Prentke-Romich Accent 800
Accent 1000
Accent 1400
PRio
PRio Mini
NuEye
NuPoint
Teltex
iPad
iPad Mini
iPad Pro (11”)
iPad Pro (12.9”)
N/A
Tobii-Dynavox
EM-12
I-13
I-16
I-110
SC Tablet
PC Eye Mini
PC Eye Plus & Eye R
Gaze Interaction
EyeMobile Plus Access
Saltillo Nova Chat 5 Plus
Nova Chat 8 Plus
Nova Chat 10 Plus
Nova Chat 12 Plus
Chat Fusion 10 Plus
ChatPoint
Smartbox
Grid Pad Go 8”
Grid Pad Go 10”
Grid Pad Pro 12” w/ mount plate
Eyegaze - Irisbond Duo Eye
Tracking Camera
Please contact the manufacturer for assistance in selecng a speech generang device.
VENDOR CONTACT INFORMATION
VENDOR PHONE NUMBER E-MAIL ADDRESS WEB SITE
Prentke-Romich 1-800-262-1984
service@prentrom.com www.prentrom.com
Teltex 1-888-515-8120
info@teltex.com www.teltex.com
Tobii-DynaVox 1-800-344-1778
css@tobiidynavox.com www.tobiidynavox.com
Salllo 1-877-397-0178
info@salllo.com www.salllo.com
Smartbox 1-844-341-7386
info@thinksmartbox.com www.thinksmartbox.com
FM608SGD (Revised 01/22/2020)
Indi 7
SECTION A
Please Print Your Information and Sign on Page 3 ( Required Information )
Oregon Telecommunication
Devices Access Program (TDAP)
www.rspf.org
ZIP Home Address Apt. # City
Email Address
Applicant (or Parent/Guardian)
Oregon Drivers License or ID #
(If you do not have an ODL or ID #, please contact TDAP)
Applicant Date of Birth
Mailing Address (If dierent than above) Apt. # City
ZIP
County
Parent/Guardian Name (If applicant is a minor)
Name of Applicant (Last, First, Middle) Phone/Cell
Other phone
( ) – ( ) –
Mailing Address of Contact Person Apt. # City ZIP
Alternate Contact Name (Last, First) Relationship
( ) –
Phone/Cell
(e.g. spouse, friend, relative, or caregiver)
Oregon Public Utility Commission
PO Box 1088, Salem, OR 97308-1088
800-848-4442 or 503-373-7171 TTY:
800-648-3458
VP: 971-239-5845
Fax: 877-567-1977 or 503-378-6047
puc.rspf@state.or.us
Please note you may be able to acquire a speech generating device through private insurance,
Medicaid or Medicare. TDAP loans speech generating devices for phone access to eligible
Oregonians who may otherwise be unable to obtain a speech generating device.
I authorize my certifying speech-language pathologist to release all appropriate and
necessary medical information required for the sole purpose of selecting the most
appropriate goods or services provided by the Oregon TDAP.
Yes
q
No
q
PAGE 2
Speech Generating Devices Application
FM608SGD (Revised 01/22/2020)
PAGE 3
Conditions of Acceptance and Agreement
for TDAP Speech Generating Devices
Please READ and SIGN the form that indicates you
understand and agree to comply with the following conditions
upon acceptance of all TDAP Speech Generating Devices (Equipment):
n All Equipment is the property of the State of Oregon and I will use it in compliance with Oregon laws and
regulations, including Oregon Administrative Rule Chapter 860 Division 033.
n I will not offer for sale, sell, give away, or loan any Equipment to anyone. I am financially responsible for any
damage to any Equipment that is not caused by normal wear and tear or acts of nature or disaster. [Note: A
price list of the most current prices for previously used and current Equipment is available upon request.]
n I am responsible for the appropriate care of all Equipment and will use it for accessing telephone and related
services.
n I will not remove the protective case from the Equipment. I will not damage or deface the Equipment (e.g.,
removing any property of Oregon identifying labels, altering the laser etching, etc.).
n I understand that the Equipment may have a web filter installed to prohibit access to websites containing
unlawful, adult or inappropriate content. The TDAP office and TDAP Vendors have my permission to monitor
the Equipment to ensure proper use.
n I will return defective or damaged Equipment at the PUC’s expense. The PUC will repair or replace the returned
Equipment at its discretion.
n If any Equipment is stolen, I will notify the local law enforcement agency within 24 hours of the time the theft is
discovered. I will provide a copy of the police report to the TDAP office within five (5) business days of the date
that I reported the theft.
n If floods, storms, fire, or other acts of nature damage the Equipment, I will submit a fire department, insurance,
police or other appropriate report about the event to the TDAP office within five (5) business days after the date
the event occurred.
n If I move to another place in Oregon, I will report my new address to the TDAP office within thirty (30) calendar
days of the move.
n I am responsible for the purchase of Equipment supplies, such as headphones, and the costs related to the
use of the Equipment, such as Wi-Fi service.
n I will return all Equipment to the TDAP office before I permanently move out of Oregon. I am liable for the
replacement cost of any Equipment I fail to return before moving out of Oregon.
n I will obtain written permission from PUC’s TDAP Manager before I travel out of the State of Oregon with any
Equipment for more than 90 days.
n If I have signed this Agreement on behalf of a minor or as a guardian for an adult, I will notify the TDAP office
about a change in responsibility within five (5) calendar days of the event (for example, the minor reaches 18 or
there is a change of guardian). I understand that TDAP will bill me for any Equipment if the minor does not sign
a new Condition of Acceptance and Agreement within 30 calendar days after the minor’s 18th birthday and I
am responsible for paying that bill.
n I understand that all Equipment is provided on a “first come, first served” basis and its availability is
contingent upon adequate funding.
All statements I have made in this application are
true and correct to the best of my knowledge.
Signature of Applicant or Parent / Guardian (If Applicant is under 18) Date
*Please provide a copy of the Power of Attorney/guardianship documentation if signing on behalf of applicant.
FM608SGD (Revised 01/22/2020)
App Name: _______________________________________________________________________________
____
PROFESSIONAL CERTIFICATION FORM
This section is ONLY to be completed by an ASHA certied speech-language pathologist.
SECTION B
PAGE 4
FM608SGD (Revised 01/22/2020)
IMPAIRMENT (CHECK ALL THAT APPLY)
o Speech
o Moderate
o Severe
o No Usable Speech
o Language
o Expressive
o Receptive
o Both
o Hard of Hearing/Deaf
o Mild o Moderate
o Severe o Profound
o Mobility
o Upper
o Lower
o Both
o Cognitive
o Mild
o Moderate
o Severe/Profound
Other Impairments - For TDAP Information Purposes Only
SPEECH GENERATING DEVICE REQUEST
Please continue to page 5
Secondary Device Requested: ____________________________________________________________
Access Method (if needed): _______________________________________________________________
SPEECH APP SELECTION (FOR IPADS ONLY)
If selecting an iPad, please provide the name of the speech app below and provide a justication for this
request as an amendment to this application.
Primary Device Requested: _______________________________________________________________
Access Method (if needed): _______________________________________________________________
Required: I hereby certify that ______________________________________________________________
requires the use of a speech generating device to communicate eectively on the phone.
(Applicant’s Name – Last, First)
Name (Print or Type) Title ASHA License Number
Street City State ZIP
Email Address
( ) –
Phone Fax
( ) –
ASHA CERTIFIED SPEECHLANGUAGE PATHOLOGIST
Signature Date
PROFESSIONAL CERTIFICATION FORM
Please provide the following information in detail as an amendment to the application:
SECTION B CONTINUED
I. Applicant’s communication abilities:
a. Ability to communicate without use of a device
b. Previous experience with devices (if applicable)
c. Why are previously owned or issued devices no longer being used (if applicable)
d. Applicant’s current means of communication
II. Selection of device:
a. List all devices considered and rationale for elimination
b. Rationale for selection of specic device
c. Indications for success with selected device
d. Describe the applicant’s experience using the selected device (if applicable)
e. Rationale for selection of an alternate (secondary) device
f. Indications for success with alternate (secondary) device
g. Describe the applicant’s experience using the alternate (secondary) device (if
applicable)
III. Using the device:
a. Expectations for applicant’s communication ability while using the device
b. Perceived duration of need to use the device
c. Plans for successful phone communication using the device
d. Speech-Language Pathologist’s continuing plans to assist the applicant in using the
device
e. Support necessary for applicant to be successful using the device (e.g. caregiver,
family members, other professionals)
PAGE 5
FM608SGD (Revised 01/22/2020)
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