ŠĻą”±į>ž’ EGž’’’@ABCD’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’’ģ„Į7 ųæbjbjUU )7|7|¶i'’’’’’’ląąąąąąą6ź:ź:ź:8";”¶=T6ŌŠ@F\[r[r[Š[e\˜ żf,)l˜ŃŃŃŃŃŃŃ$ØÕ Č× ;ѝąĮne\e\ĮnĮn;Ńɇąąr[Š[ŪŲÓɇɇɇĮnh ąr[ąŠ[ŃɇĮnŃɇņɇ»ˆNI½Øąą™ær[ @ *S1ņ9Å6“7ź:)z8ń¾0™æ|īÓ0Ō!æxŅŲa|h ŅŲ™æɇōž’¤ąąąąŁNAME:  FORMTEXT      DATE OF EVALUATION:  FORMTEXT      ADDRESS:  FORMTEXT      DATE OF BIRTH:  FORMTEXT      TELEPHONE:  FORMTEXT      AGE:  FORMTEXT      REFERRED BY:  FORMTEXT      MEDICAL DIAGNOSIS:  FORMTEXT      LICENSED SLP:  FORMTEXT      SLP DIAGNOSIS:  FORMDROPDOWN DATE OF REPORT:  FORMTEXT      DATE OF ONSET:  FORMTEXT      SPEECH-LANGUAGE PATHOLOGY EVALUATION FOR SPEECH GENERATING DEVICE (SGD) II. CURRENT COMMUNICATION IMPAIRMENT Impairment Type, Severity The patient presents with  FORMDROPDOWN  due to  FORMTEXT      .  FORMTEXT        FORMCHECKBOX  Given the severity of the communication impairment as described above the patient is functionally nonspeaking.  FORMCHECKBOX  As indicated above, the patient s speaking rate was  FORMTEXT       words per minute (WPM). Research on speaking rate and intelligibility in degenerative diseases has found speaking rates less than or equal to 50% of normal (range 190 – 220 WPM) are predictive of imminent precipitous decline (e.g., to the point of no usable speech in less than 3 months) in speech intelligibility. Anticipated Course of Impairment The patient’s condition is  FORMDROPDOWN  in nature and  FORMDROPDOWN  is expected to  FORMDROPDOWN . Therefore it is anticipated that the patient’s natural speech will not be sufficient to meet daily communication needs for  FORMDROPDOWN  Comprehensive Assessment Hearing Status The patient has  FORMDROPDOWN  of hearing impairment. The patient’s  FORMDROPDOWN  has  FORMDROPDOWN  of hearing impairment. Informal observation of functional listening performance during the SGD assessment revealed the patient and/or caregiver required the following modifications regarding auditory output to use a SGD effectively. ModificationPatientCaregiverNo modifications FORMCHECKBOX  FORMCHECKBOX Headphones FORMCHECKBOX  FORMCHECKBOX Use of dual visual display to read messages FORMCHECKBOX  FORMCHECKBOX Specific speech output options.  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX With modifications as listed above, the patient demonstrates adequate hearing ability to use a SGD to communicate functionally. Visual Status The patient has a history of  FORMDROPDOWN . The patient’s  FORMDROPDOWN  has a history of  FORMDROPDOWN . Informal observation of functional visual performance during the SGD assessment revealed the patient and/or caregiver required the following modifications to use a SGD effectively given current vision status. ModificationPatientCaregiverNo modifications FORMCHECKBOX  FORMCHECKBOX Font size used on SGD display and/or symbol labels ( gloss ) should be:  FORMDROPDOWN   FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Picture-symbols and/or icons should be the following size:  FORMDROPDOWN   FORMTEXT       FORMCHECKBOX  FORMCHECKBOX A flat display is required to reduce visual tracking requirements (e.g., need to alternate focus between keyboard and display to monitor selections) FORMCHECKBOX  FORMCHECKBOX Color contrasts are needed to enhance text or symbol discrimination such as:  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Number of items per display should be:  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Auditory feedback from device is needed to assist in message preparation/selection. FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX With modifications as listed above, the patient demonstrates the visual abilities to use a SGD to communicate functionally. Physical Status The patient was able to successfully access SGDs presented at the evaluation with the following selection technique/modifications. CheckSelection TechniqueTypeAdditional Information FORMCHECKBOX Manual direct selection FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Optical Direct Selection FORMTEXT       FORMTEXT       FORMCHECKBOX High Tech Eye Gaze Direct Selection FORMTEXT       FORMTEXT       FORMCHECKBOX Scanning FORMDROPDOWN ,  FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Morse Code FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Requires access modifications over time due to degenerative condition FORMTEXT       FORMTEXT      The patient uses  FORMDROPDOWN  for mobility. Therefore, a wheelchair mounting system  FORMDROPDOWN  to transport the patient’s SGD. With the above modifications/considerations, the patient possesses the physical abilities to effectively use a SGD and required accessories to communicate. Language Skills The patient presents with  FORMDROPDOWN  impairment in language functioning as it relates to using an appropriate SGD. Based on patient report and observation of the patient’s language and literacy skills during the evaluation, the patient possesses the following skills/abilities. Skill/AbilityMasteryFollows simple instructions (e.g., “Look at me.” “Turn your head.” “Open your mouth.”) FORMDROPDOWN Follows complex instructions FORMDROPDOWN Follows general conversation FORMDROPDOWN Reads/comprehends common words  FORMDROPDOWN Reads/comprehends simple sentences FORMDROPDOWN Reads comprehends short paragraphs FORMDROPDOWN Reads the newspaper FORMDROPDOWN Spells common words FORMDROPDOWN Generates basic messages using writing/spelling skills FORMDROPDOWN Generates complex messages using writing/spelling skills FORMDROPDOWN Generates basic messages by using pictographic symbols FORMDROPDOWN Generates complex messages using pictographic symbols FORMDROPDOWN Generates messages using generative symbols (e.g., MinSpeak"!) FORMDROPDOWN Given the patient s language/literacy functioning, a SGD that provides message production using  FORMDROPDOWN  will be required. Following  FORMDROPDOWN  instruction, the patient demonstrated the linguistic capacity to generate  FORMDROPDOWN  messages on an SGD with FORMDROPDOWN .  FORMTEXT       The patient s linguistic performance with the SGDs presented during the evaluation indicated the necessary language skills to functionally communicate using a SGD. Cognitive Skills The patient presents with  FORMDROPDOWN  impairment in cognitive functioning as it relates to ability to use an appropriate SGD.  FORMTEXT       The patient s attention, memory and problem solving skills observed during the evaluation appeared functional to learn to use a SGD successfully. For example, during the  FORMDROPDOWN  assessment/training trials, the patient demonstrated independence or progress in mastering the following SGD features. FeatureMasteryTurns SGD on and off FORMDROPDOWN Navigates within and between display pages on a dynamic display SGD FORMDROPDOWN Uses dictionary features to locate vocabulary not available on pre-programmed displays FORMDROPDOWN Uses word-prediction FORMDROPDOWN Retrieves messages stored under letter codes or symbol codes FORMDROPDOWN Stores messages under letter codes FORMDROPDOWN Stores messages under picture symbols FORMDROPDOWN Learns icon-code sequences to retrieve words on SGD (e.g., Unity"! Core)  FORMDROPDOWN Navigates within SGD “Menu” options to modify device options (e.g., voice, scan rate, feedback).  FORMDROPDOWN The patient demonstrates the necessary cognitive abilities (i.e., attention, memory, and problem-solving) skills to learn to use a SGD to achieve functional communication goals.  FORMTEXT         III. DAILY COMMUNICATION NEEDS Specific Daily Functional Communication Needs The results of a communication needs interview conducted with the patient, relevant family members and caregivers revealed the following communication needs. Communicative Activity. Communication to:Communication Partner(s)Communicative Environment(s)Is Need Met with Natural Speech and/or Low Tech?Express basic physical needs/wants. FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAExpress needs/wants in emergences.  FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger  FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAExpress detailed physical needs/wants.  FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAParticipate in decision-making (e.g., discuss choices for end-of-life care). FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone  FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAParticipate in conversation. FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NATell personal stories and anecdotes. FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAReport medical status and complaints. FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAAsk questions. FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAGive responses. FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NA FORMTEXT       FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NA FORMTEXT       FORMCHECKBOX spouse  FORMCHECKBOX immediate family  FORMCHECKBOX extended family  FORMCHECKBOX friends  FORMCHECKBOX healthcare provider  FORMCHECKBOX non-reader  FORMCHECKBOX hearing impaired  FORMCHECKBOX visually impaired  FORMCHECKBOX stranger FORMCHECKBOX home  FORMCHECKBOX medical facility  FORMCHECKBOX community  FORMCHECKBOX support group  FORMCHECKBOX work/school  FORMCHECKBOX telephone FORMCHECKBOX yes  FORMCHECKBOX no  FORMCHECKBOX NAAbility to Meet Communication Needs With Non-SGD Treatment Approaches Speech therapy to improve/increase functional speech is not a viable option to meet the patient’s communication needs because:  FORMCHECKBOX  The patient’s has a degenerative condition for which speech/language therapy is not effective.  FORMCHECKBOX  The patient received speech/language treatment for  FORMTEXT       with no significant changes in speech/language functioning.  FORMCHECKBOX  The patient s speech/language functioning has been static for  FORMTEXT       and no improvement is expected. The results of the communication needs assessment as documented in the previous section indicate the majority of patient’s daily functional communication needs cannot be met with natural speech and/or low tech communication devices. Therefore the patient requires a SGD to achieve and/or maintain functional communication ability in activities of daily living. IV. FUNCTIONAL COMMUNICATION GOALS The patient’s immediate, short term and long term goals and estimated times to completion following receipt of the recommended SGD are listed below. Functional Communication Goals Patient will use SGD independently to: ImmediateShort TermLong TermCall for help from a spouse/caregiver in another room in emergency.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Contact a family member, friend or public agency for help on the telephone in emergency.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Communicate physical needs and emotional status to spouse/caregiver on a daily basis, as needed.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Describe physical symptoms and ask any questions when interacting with physician and other health care professionals as needed.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Engage in social communication exchanges with immediate family members in person.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Engage in social communication exchanges with extended family members and friends by use of the telephone.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Engage in social communication exchanges with friends at their homes and in other community settings.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Use the telephone to make contact friends and extended family to interact socially.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Ask questions and provide responses in community-based transactions (e.g., ordering a meal in a restaurant, asking directions, etc.)  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Instruct caregivers on the care requirements (e.g., transfers, bathing, moving from wheelchair to the car.)  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Participate in family planning decisions (e.g., household management, finances, childrearing, etc.)  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Participate in support groups.  FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX V. RATIONALE FOR DEVICE SELECTION This individual requires a speech generating device with the following features to meet functional communication goals as stated in the previous section of this report. Input Features/ Selection Technique CheckSelection TechniqueTypeRationale FORMCHECKBOX Manual direct selection FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Optical Direct Selection FORMTEXT       FORMTEXT       FORMCHECKBOX High Tech Eye Gaze Direct Selection FORMTEXT       FORMTEXT       FORMCHECKBOX Scanning FORMDROPDOWN ,  FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Morse Code FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Provides multiple access technique options to accommodate changing physical condition FORMTEXT       FORMTEXT       FORMCHECKBOX Keyboard  FORMTEXT       FORMTEXT       FORMCHECKBOX Dynamic display FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Message Characteristics/Features CheckCharacteristic or FeatureRationale FORMCHECKBOX Message generation using spelling FORMTEXT       FORMCHECKBOX Message generation using a combination of pre-programmed whole words and spelling FORMTEXT       FORMCHECKBOX Message generation using pictographic symbols (e.g., PCS, Dynasyms, custom symbols) FORMTEXT       FORMCHECKBOX Message generation using multi-meaning icon coding (e.g., MinSpeak"!) FORMTEXT       FORMCHECKBOX Message selection using photographs and/or tangible symbols FORMTEXT       FORMCHECKBOX Ability to adjust font/symbol size to accommodate visual needs FORMTEXT       FORMCHECKBOX Flat display to reduce visual tracking requirements FORMTEXT       FORMCHECKBOX Ability to adjust color and contrasts to accommodate visual or cognitive needs FORMTEXT       FORMCHECKBOX Ability to adjust number of items per display to accommodate visual, physical and/or cognitive needs FORMTEXT       FORMCHECKBOX Ability to store/edit/retrieve whole messages under word/symbol buttons FORMTEXT       FORMCHECKBOX Ability to store/edit/retrieve narrative messages (e.g., stories, reports, speeches) from message files FORMTEXT       FORMCHECKBOX Provides word/symbol prediction rate acceleration techniques FORMTEXT       FORMCHECKBOX Provides abbreviation expansion (letter coding) rate acceleration techniques FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT      Output Features CheckFeature or OptionSpecifications if ApplicableRationale  FORMCHECKBOX Synthesized speech  FORMTEXT      Essential for:  FORMCHECKBOX message generation using spelling  FORMCHECKBOX telephone  FORMCHECKBOX non-reading partners  FORMCHECKBOX visually impaired partners  FORMCHECKBOX Digitized speech FORMDROPDOWN Essential for:  FORMCHECKBOX telephone  FORMCHECKBOX non-reading partners  FORMCHECKBOX visually impaired partners  FORMCHECKBOX User display size FORMDROPDOWN  FORMTEXT       FORMCHECKBOX Dual display (user/listener) FORMTEXT      Essential for:  FORMCHECKBOX hearing impaired partners  FORMCHECKBOX noisy environments FORMCHECKBOX Auditory feedback from device to assist in message preparation/selection FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Other Features CheckFeature or OptionSpecifications if applicableRationale FORMCHECKBOX Wheelchair mounting System FORMTEXT       FORMTEXT       FORMCHECKBOX Small/lightweight for carrying by user FORMTEXT       FORMTEXT       FORMCHECKBOX Length of use after battery charged FORMTEXT       FORMTEXT       FORMCHECKBOX Display viewable in direct sunlight FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      Recommended Speech Generating Device Code Based on the patient’s communication needs and considering the patient’s visual, hearing, physical, language and cognitive status as well as specified features as described in this report, SGDs in the  FORMDROPDOWN  Medicare/CPT code category were evaluated to determine the most appropriate SGD to meet the patient’s functional communication goals. Equipment and Procedures Used in Assessment Speech Generating Devices and Accessories Evaluated The following SGDs and accessories were presented for evaluation.  FORMTEXT       Procedures Used in SGD Trials To assess the patient s ability to use the selected SGDs the following procedures were used.  FORMTEXT       Outcome of SGD Trials For the following reasons the  FORMTEXT       was selected as the most appropriate SGD for the patient.  FORMTEXT       The other SGDs evaluated were ruled out for the following reasons.  FORMTEXT       Speech Generating Device and Accessories Recommended The individual's ability to achieve functional communication goals requires the acquisition and use of the SGD, mounting/carrying devices and accessories listed below. This SGD represents the clinically most appropriate device for ( FORMTEXT      ). SGD, Mounting System, or AccessoryMedicare/CPT CodeManufacturer/Vendor FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMCHECKBOX  Important: Contact family for specifications regarding tubing size for wheelchair mounting system. Patient/Family Support of Speech Generating Device The patient’s  FORMDROPDOWN  was present at the evaluation. The  FORMDROPDOWN  was supportive of the patient using the SGD and agreed to the necessity of the SGD for meeting the patient’s communicative needs in activities of daily living. Physician Involvement Statement This report was forwarded to the treating physician  FORMTEXT       on  FORMTEXT      . The physician was asked to write a prescription for the recommended SGD and accessories. VI. TREATMENT PLAN Following receipt of the recommended SGD and accessories, it is recommended the patient receive  FORMTEXT       of treatment sessions addressing the acquisition of the functional communication goals described in part IV of this report. The patient’s family and/or primary caregivers are encouraged to participate in the treatment sessions so they may learn to assist the patient in the use of the SGD as needed. The patient’s treatment goals would best be met in  FORMDROPDOWN  setting. Following discharge from treatment, the patient will be reevaluated as needed (at the request of the patient, physician, or family) to determine the need for updates/modifications of the SGD. VII. SLP ASSURANCE OF FINANCIAL INDEPENDENCE AND SIGNATURE The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of any SGD. Evaluating SLP name: FORMTEXT      ASHA Certification #: FORMTEXT      State License #: FORMTEXT           Name:  PAGE 11. 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jOJQJU^JmHnHujOJQJU^Jj–hOJQJU^J,›'›œœ<œdœfœˆœ°œ²œ“œøœŗœ¾œĄœÄœĘœŹœĢœłłØ¬łłØ˜łłØ¦¤¦¤¦¤¦¤¦P$$If–lÖ0”’Ų ,"D T tąö6ööÖ’’Ö’’Ö’’Ö’’4Ö4Ö laö$Ifžœ œ¢œ¬œ®œ²œ“œ¶œŗœ¼œĄœĀœĘœČœĢœŚœÜœčœźœīœšœōœüœžœńęÕęĪÉÉÉÉĮ“«““«“Į0J5OJQJ^J0JOJQJ^JmHnHu0JOJQJ^Jj0JOJQJU^J5OJQJ^J jU OJQJ^J jOJQJU^JmHnHujOJQJU^Jj mOJQJU^JĢœōœžœżżūūū' 0&P1h°Š/ °ą=!°"°# $ %°tD’’’’Text2xD’’’’Text112tD’’’’Text3tD’’’’Text8tD’’’’Text4tD’’’’Text9tD’’’’Text5D’’’’Text115MInsert medical diagnosis and ICD-9 code. For example: CVA (436), ALS (335.20)tD’’’’Text6ŗD’’’’f€ Dropdown1’’ __________Apraxia (784.69)Aphonia (784.41)Dysarthria (784.5)Aphasia (784.3)$Aphasia (784.3) and Apraxia (784.69)'Dysarthria (784.5) and Apraxia (784.69)xD’’’’Text114xD’’’’Text113ØD’’’’f€’’ __________Apraxia (784.69)Aphonia (784.41)Dysarthria (784.5)Aphasia (784.3)$Aphasia (784.3) and Apraxia (784.69)'Dysarthria (784.5) and Apraxia (784.69)šD’’’’Text136<Insert medical diagnosis and ICD-9 Code (e.g., ALS (335.20).fD’’’’~Briefly summarize SLP diagnostic assessment (e.g., results of formal and informal tests, speech intelligibility and WPM rate).vD’’’’eCheck79vD’’’’eCheck80öD’’’’Text134?Fill in speaking rate in Words Per Minute (WPM) E.g., (90 WPM)ņD’’’’f€ Dropdown2’’ ___________ progressivechronic and stable deterioratingD’’’’f€ Dropdown3’’ __________speech intelligibilityability to phonateverbal expression,D’’’’f€ Dropdown4’’ ____________remain at the present level,continue to decline with disease progressionōD’’’’f€ Dropdown36’’ ___________the remainer of life.the forseeable future.ĄD’’’’f€ Dropdown32’’ _________ a history no historyÜD’’’’f€ Dropdown37’’ __________spouseguardianprimary caregiverĄD’’’’f€ Dropdown32’’ _________ a history no historyvD’’’’eCheck42vD’’’’eCheck43vD’’’’eCheck34vD’’’’eCheck35vD’’’’eCheck34vD’’’’eCheck35RD’’’’Text68nDescribe speech synthesizer options needed (e.g., speech synthesizer type, loudness setting, digitized speech)vD’’’’eCheck34vD’’’’eCheck35vD’’’’Text13vD’’’’eCheck34vD’’’’eCheck35žD’’’’f€’’ _________visual acuity WNL (visual acuity WNL with corrective lenses"mild uncorrected visual impairment$severe uncorrected visual impairment blindnessÜD’’’’f€ Dropdown37’’ __________spouseguardianprimary caregiveržD’’’’f€’’ _________visual acuity WNL (visual acuity WNL with corrective lenses"mild uncorrected visual impairment$severe uncorrected visual impairment blindnessvD’’’’eCheck32vD’’’’eCheck33$D’’’’f€ Dropdown39’’ ________10 point12 point14 point16 point18 point20 point22 point24 pointbD’’’’|Specifiy optimal font size for use in text and or symbol "gloss" labels on SGD if not available in previous pull down menu. vD’’’’eCheck32vD’’’’eCheck33ōD’’’’f€ Dropdown40’’_______1" x 1"2" x 2"3" x 3"4" x 4"5" x 5"6" x 6"D’’’’OSpecify optimal symbol size if not indicated in previous pull down menu option.vD’’’’eCheck32vD’’’’eCheck33vD’’’’eCheck32vD’’’’eCheck33ˆD’’’’Text34‰Describe color contrasts required to enhance visability of text/symbols on SGD display e.g, black on white background, color coding, etc.vD’’’’eCheck32vD’’’’eCheck33D’’’’Text65FSpecify number of items per display for optimal visual discrimination.vD’’’’eCheck32vD’’’’eCheck33vD’’’’eCheck32vD’’’’eCheck33ĘD’’’’Text104'Add additional modifications if needed.vD’’’’eCheck32vD’’’’eCheck33vD’’’’eCheck36ŗD’’’’f€ Dropdown28’’________ Two handsOne handˆD’’’’Text66‰Briefly describe ability to use direct selection AND any modifications needed for success (e.g., keyguard, finger splint, stylus, etc.). vD’’’’eCheck37D’’’’Text42HProvide name of optical direct device (e.g., Head Mouse, Tracker, etc.).xD’’’’Text47Briefly describe success in using optical direct selection AND any modifications required (e.g., neck brace, head support, etc.).vD’’’’eCheck38ōD’’’’Text43?Indicate name of device used (e.g., ERICA, L.C. Technologies). xD’’’’Text48Briefly describe success in using this selection technique AND any modifications required (e.g., neck brace, head support, etc.).vD’’’’eCheck39ŌD’’’’f€ Dropdown17’’________ AutomaticDirectedInverseStepÖD’’’’f€’’_______linearcircular row-columngroup-row-column2D’’’’Text45^Briefly describe switch set up required for success(e.g., location of switch, mounting, etc.).vD’’’’eCheck40ŗD’’’’f€ Dropdown19’’_____ One switch Two switch<D’’’’Text46cBriefly describe set up and mounting for switches used for Morse Code required for successful use. vD’’’’eCheck41vD’’’’Text67xD’’’’Text135ŹD’’’’f€ Dropdown14’’ ________no assistive devicesa cane a quad canea walker'a manual wheelchair (partner propelled)$a manual wheelchair (self propelled)a power wheelchair a scooterD’’’’f€ Dropdown20’’ __________will be requiredwill not be requiredmay need to be considered¾D’’’’f€ Dropdown21’’_____nomildmoderatesevereD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesunablenot applicable²D’’’’f€ Dropdown22’’ _____________generative spelling.a combination of words and generative spelling2a combination of spelling and pictographic symbols/a combination of words and pictographic symbolspictographic symbols*generative symbols (e.g., MinSpeak, Bliss)#photographs and/or tangible symbolsÄD’’’’f€ Dropdown24’’_______briefmoderate intensiveD’’’’f€ Dropdown23’’________short telegraphicsingle word/symbolcomplete sentence2D’’’’f€’’ __________no assistance or cueing occassional assistance or cueingfrequent assistance or cueingdD’’’’Text53wProvide additional detail as needed to support the patient's potential use a SGD for functional communication in ADLs. ¬D’’’’f€’’______nomildmoderatesevereD’’’’RInsert scores from cognitive functioing scales (e.g., Rancho TBI scale) if needed.D’’’’f€ Dropdown26’’_______one hourtwo hour three hourone weektwo week three week one monthD’’’’f€ Dropdown27’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicableD’’’’f€’’________ independent minimal cues moderate cues maximal cuesnot applicable@D’’’’kProvide additional detail as needed to support the patient's cognitive ability to use (learn to use) a SGD.tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62vD’’’’Text54tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62vD’’’’Text55tD’’’’eCheck4tD’’’’eCheck5vD’’’’eCheck13tD’’’’eCheck6tD’’’’eCheck7vD’’’’eCheck14vD’’’’eCheck15vD’’’’eCheck16vD’’’’eCheck56tD’’’’eCheck8tD’’’’eCheck9vD’’’’eCheck10vD’’’’eCheck17vD’’’’eCheck11vD’’’’eCheck12vD’’’’eCheck60vD’’’’eCheck61vD’’’’eCheck62vD’’’’eCheck18vD’’’’eCheck19¬D’’’’Text56Fill in length of treatmentvD’’’’eCheck20ąD’’’’Text575Indicate the approximate duration in months or years.vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck29vD’’’’eCheck30vD’’’’eCheck31vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck63vD’’’’eCheck64vD’’’’eCheck65vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28®D’’’’Text62Add custom goal for patient.vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28®D’’’’Text62Add custom goal for patient.vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28®D’’’’Text62Add custom goal for patient.vD’’’’f€ Dropdown38’’ _________(within one week)(within two weeks)(within three weeks)(within four weeks)(within five weeks)(within six weeks)(within eight weeks)(within three months)(within four months)(within five months)(within six months)(within one year)vD’’’’eCheck26vD’’’’eCheck27vD’’’’eCheck28vD’’’’eCheck36¤D’’’’f€’’_______ Two handsOne handLD’’’’qIndicate reason this feature is required. Eg., Patient could successfully use left hand to access SGDs presented.vD’’’’eCheck37śD’’’’HProvide name of optical direct device (e.g., Head Mouse, Tracker, etc.).hD’’’’Indicate reason this feature is required. e.g., Access was most successful with optical selection accessory (i.e., head mouse).vD’’’’eCheck38čD’’’’?Indicate name of device used (e.g., ERICA, L.C. Technologies). fD’’’’~Indicate reason this feature is required. E.g., Patient's most successful access ability was using eyes for selections on SGD.vD’’’’eCheck39¾D’’’’f€’’_______ AutomaticDirectedInverseStepÖD’’’’f€’’_______linearcircular row-columngroup-row-columnhD’’’’Indicate reason this feature is required. E.g., Patient was most successful making selections on an SGDs using scanning access.vD’’’’eCheck40ŖD’’’’f€’’_______ One switch Two switchdD’’’’}Indicate reason this feature is required. E.g., Patient was most efficient and effective accessing SGDs using this technique.vD’’’’eCheck41vD’’’’Text67D’’’’YIndicate the reason this feature is required. E.g., Patient's condition is degenerative. vD’’’’eCheck49vD’’’’Text72nD’’’’‚Provide rationale for feature. E.g., Patient was most effecient using keyboard-based SGDs. Also indicate if keyguard is necessary.vD’’’’eCheck48vD’’’’Text70zD’’’’ˆIndicate the reason feature is required. e.g., Patient was most successful using a Dynamic Display. Also indicate if keyguard is needed.vD’’’’eCheck57ĪD’’’’Text117+Indicate other selection technique feature.xD’’’’Text118D’’’’OIndicate the reason, based on the patient assessment, this feature is required.vD’’’’eCheck36fD’’’’~Indicate reason feature is required. E.g., Patient has intact literacy skills and perfers to contruct messages using spelling.vD’’’’eCheck68rD’’’’Text124}Reason for feature. E.g., Message construction was most efficient using SGDs providing programmed common words with spelling.vD’’’’eCheck44:D’’’’hReason for feature. E.g., Spelling insufficient. Patient needs picture symbols to represent vocabulary. vD’’’’eCheck69nD’’’’Text125{Reason for feature. Patient demostrated potential to use and perferred SGDs that provided this message construction option.vD’’’’eCheck67†D’’’’Text123‡Reason for feature. Patient was most successful selecting messages on SGDs where messages were represented using these symbol options. vD’’’’eCheck384D’’’’eReason for feature. E.g., Patient needed font size of ____ to accomodate for visual acuity deficits. vD’’’’eCheck39FD’’’’nReason for feature. E.g., Patient has impaired visual tracking ability so does best with this type of display.vD’’’’eCheck40BD’’’’lReason for feature. E.g., Patient was most efficient in locating desired vocabulary with color enhancement. vD’’’’eCheck41bD’’’’|Reason for feature. E.g., Patient was most successful accessing vocabulary from a display with 15 - 20 word/symbol buttons. vD’’’’eCheck36^D’’’’zReason for feature. E.g., This feature will increase communication efficiency in communicating frequently needed messages.vD’’’’eCheck45hD’’’’Reason for feature. E.g., The patient needs this feature to meet communcation goals as descibed in previous sections of report.vD’’’’eCheck46ZD’’’’xReason for feature. E.g., The patient demonstrated the ability to use this feature to increase communication efficiency.vD’’’’eCheck47RD’’’’tReason for feature. E.g., Patient demonstrated the ability to use this feature to increase communication efficiency.vD’’’’eCheck50ĢD’’’’Text132*Indicate other feature not already listed.D’’’’OIndicate the reason, based on the patient assessment, this feature is required.vD’’’’eCheck51¾D’’’’*Indicate other feature not already listed.D’’’’OIndicate the reason, based on the patient assessment, this feature is required.vD’’’’eCheck58¾D’’’’*Indicate other feature not already listed.D’’’’OIndicate the reason, based on the patient assessment, this feature is required.vD’’’’eCheck52vD’’’’Text75vD’’’’eCheck74vD’’’’eCheck70vD’’’’eCheck71vD’’’’eCheck72vD’’’’eCheck53(D’’’’f€ Dropdown30’’_______8 minutes or less9 to 20 minutes21 to 40 minutesgreater than 40 minutesvD’’’’eCheck70vD’’’’eCheck71vD’’’’eCheck72vD’’’’eCheck54øD’’’’f€ Dropdown31’’_______smallmediumlargeBD’’’’lIndicate reason for feature. E.g., Patient needs large visual display to accomodate visual acuity deficits. vD’’’’eCheck55vD’’’’Text76vD’’’’eCheck76vD’’’’eCheck77vD’’’’eCheck66lD’’’’Text133zReason for feature. E.g., Patient is blind and needs a device that provides auditory feedback during message construction.vD’’’’eCheck59¦D’’’’Text122List additional featurexD’’’’Text121D’’’’OIndicate the reason, based on the patient assessment, this feature is required.vD’’’’eCheck52vD’’’’Text77üD’’’’IIndicate reason for feature. E.g., Required for patient to transport SGD.vD’’’’eCheck53vD’’’’Text78D’’’’VIndicate reason for feature. E.g., Required to enable patient to physically carry SGD.vD’’’’eCheck54vD’’’’Text79dD’’’’}Indicate reason for feature. E.g., Required to assure patient can use device for duration needed to meet communication needs.vD’’’’eCheck55xD’’’’Text128VD’’’’vIndicate reason for feature. E.g., Patient spends considerable time outdoors and needs to communicate in this setting.vD’’’’eCheck78¤D’’’’Text105List addtional featurevD’’’’Text81D’’’’OIndicate the reason, based on the patient assessment, this feature is required.HD’’’’f€’’______E2500 (digitized 8 min./less)E2502 (digitized 8 - 20 min.)E2504 (digitized 20 - 40 min.)E2506 (digitized > 40 mins.)(E2508 (synthesized, direct contact only)/E2510 (synthesized, multi acess, multi message)E2511 (SGD software)RD’’’’tList SGDs and accessories presented during the evaluation, including manufacturer (e.g., LightWriter SL85, Zygo....).D’’’’bBriefly, but completely describe procedures for presenting/evaluating SGDS during the assessment. °D’’’’Text129Insert name of SGD selected.^D’’’’zProvide your rationale for why the selected SGD is the best fit based on patient needs (specifications) and SGD features. €D’’’’Text130„Briefly describe why the other SGDs were ruled out. Why were they not the best fit based on patient specifications and SGD features?¬D’’’’Text82Insert name of beneficiary.ĀD’’’’Text92&Insert name of SGD, Mount or AccessoryčD’’’’f€’’ ______E2502E2504E2500E2506E2508E2510E2511E2599E2512 D’’’’Text106IInsert the name, address and phone number of the SGD Manufacturer/Vendor.ĀD’’’’Text92&Insert name of SGD, Mount or AccessoryčD’’’’f€’’ ______E2502E2504E2500E2506E2508E2510E2511E2599E2512 D’’’’Text106IInsert the name, address and phone number of the SGD Manufacturer/Vendor.ĀD’’’’Text92&Insert name of SGD, Mount or AccessoryčD’’’’f€’’ ______E2502E2504E2500E2506E2508E2510E2511E2599E2512 D’’’’Text106IInsert the name, address and phone number of the SGD Manufacturer/Vendor.ĀD’’’’Text92&Insert name of SGD, Mount or AccessoryčD’’’’f€’’ ______E2502E2504E2500E2506E2508E2510E2511E2599E2512 D’’’’Text106IInsert the name, address and phone number of the SGD Manufacturer/Vendor.ĀD’’’’Text92&Insert name of SGD, Mount or AccessoryčD’’’’f€’’ 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