SETTLEMENT AGREEMENT BETWEEN THE UNITED STATES OF AMERICA AND THE CITY OF PHILADELPHIA AND THE PHILADELPHIA POLICE DEPARTMENT

Attachment B: Model Communication Assessment Form

We ask for this information so we can communicate effectively with individuals with disabilities. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask [insert the name and title of the Arresting Officer, Desk Sergeant, or other Police Department Personnel who the individual should contact].

Date:

Name of individual with a disability:

Nature of Disability:

   Deaf

   Hard of Hearing

   Speech Impairment

   Other: __________________

 

Name of companion (if applicable):                                     

Relationship to individual with a disability:

   Self

   Family member

   Friend

   Other: ________________

 

Does the person with a disability want a qualified interpreter or an 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)

   Videophone

   Assistive listening device (sound amplifier)

   Qualified note-taker

   Writing back and forth

   Other (explain): __________________

 

If the person with a disability is IN CUSTODY, which of the following should be provided for communication with Police Personnel, Family, Companion, and Attorney?

   Qualified interpreter (onsite or video remote interpreting)

   Videophone

   Telephone handset amplifier

   Telephone compatible with hearing aid

   TTY/TDD

   Flasher for incoming calls

   Paper and pen for writing notes

   Other (explain): __________________________________

 

Any questions?