United States of America v. Franciscan St. James Health - Settlement Agreement

EXHIBIT A

Model Communication Assessment Form

We ask this information so we can communicate effectively with Patients and/or Companions. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask your nurse or other Hospital Personnel.

Date:

Name of Patient or Companion:

Nature of Disability:

Deaf

Hard of Hearing

Other: __________________

Relationship to Patient:

Self

Family member

Friend

Other: ________________

Does the person with a disability want an onsite professional sign language or oral interpreter?

Yes. Choose one (free of charge):

American Sign Language (ASL)

Signed English

Oral interpreter

Other. Explain: _________________

No.

Which of the following would be helpful for the person with a disability? (free of charge)

TTY/TDD (text telephone)

Assistive listening device (sound amplifier)

Qualified note-takers

Writing back and forth

Other. Explain: __________________

If the person with a disability, or the Patient who the person with a disability is with, is

ADMITTED to the hospital, which of the following should be provided in the patient room?

Video remote interpreting

Telephone handset amplifier

Telephone compatible with hearing aid

TTY/TDD

Flasher for incoming calls

Paper and pen for writing notes

Other. Explain: __________________________________

Any questions?

Please call _________(voice),_______________ (TTY), or visit us during normal business hours. We are located in room ____________________________