Exhibit A

ATTACHMENT A: COMMUNICATION ASSESSMENT FORM

____________________am/pm Date/Time
_______________________ Name of Person with Disability	_______________________ Patient's Name (if not person with disability)
Nature of Disability:	Relationship to Patient:
__Deaf	__Self
__ Hard of Hearing	__ Family Member
__ Speech Disability	__Friend / Companion
__ Other: ______________	__ Other: ______________

Do you want a professional sign language or oral interpreter for your visit?

__No. I do not use sign language and do not use interpreters to lip read.
__No. I prefer to have family members/ friends help with communication.
__No. I do not feel an interpreter is necessary or do not want one for this visit.
__Yes. Choose one (free of charge):

__American Sign Language (ASL) interpreter
__Pidgin Signed English (PSE) interpreter
__Signed English interpreter
__Oral interpreter
__Other. Explain: _____________________________

Which of these would be helpful for you for effective communication? (free of charge)

__TTY/TDD (text telephone)

__Assistive listening device (sound amplifier)
__Qualified note-takers

__Writing back and forth
__CART: Computer-assisted Real Time Transcription Service
__Other. Explain: _________________________________________

We ask this information so we can communicate with you effectively. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask a member of our office staff.

Any questions? Please call our office, ______________(voice), ______________ (TTY), or visit us during normal business hours.