ECDS Occupational Therapy Report

Electronic Communication Devices Scheme

Equipment Application: Occupational Therapy Report

Office use only:

Client ID: Application #: Date of Report: Enter a date.

______

Office Use Only

Speech pathologist involvement:

Does the client have a current speech pathologist (SP)Yes ☐ No ☐

If yes, have you collaborated with the SP regarding this application?Yes ☐ No ☐

If known, please complete the speech pathologist’s contact details on the front page of this form.

In the space below, please briefly describe the nature of the collaboration (for example was a joint trial completed?):

Background Information

Briefly outline the person’s living situation, daily activities or programs and allied health supports:

Physical skills & mobility: e.g. How does the person get around?

Related Communication Device & Means of Access

What is the client’s communication device and means of access (either existing or part of a current application for funding):

Is the person’s condition changing rapidly?Yes ☐ No ☐

If ‘yes’, please provide details:

Details of this application

What equipment are you applying for with this application? Tick all that apply:

☐Mounting system

☐Switch or access method

Comments:

Has the client had a ComTEC advisory session that relates to this application? Yes ☐ No ☐

If yes, please attach copy of report or briefly describe the outcome:

Requirements of the mounting system or access method:

Please provide details of the requirements of the mounting system or access method. For example: optimal device position, details of equipment that mount will attach to (i.e. make/model of wheelchair, need for mount to be removable or swingaway, side that mount will attach to):

Outcomes of the trial & clinical justification:

Please provide details of the equipment considered or trialled and the outcome of the trials (note: wherever practicable equipment should be trialled). Supporting photos of the trial should be attached to this application where possible

Photos of the trial should be attached to support this application where ever possible:

Photo #1:

Photo #2:

Photo #3:

Your rationale for prescribing this particular piece/s of equipment:

Who will be fitting the mount or setting up the access method?

Details of person fitting the mount, if approved (please advise if assistance from ECDS is required)

Exploration of Options

List ALL the assistive technology you have trialled or considered

Reasonable and Necessary Supports (NDIS participants)

The following section must be completed for applications for an NDIS participant.

Equipment funded by the National Disability Insurance Scheme (NDIS) must comply with section 34 of the National Disability Insurance Scheme Act 2013, ‘Reasonable and Necessary Supports’. For further information, refer to the NDIS webpage on 'What are reasonable and necessary supports?'

The following criteria have been extracted from section 34 of the National Disability Insurance Scheme Act 2013 and must be satisfied in relation to the funding or provision of communication assistive technology.

How will the equipment assist the participant to pursue the goals, objectives and aspirations included in the participant’s statement of goals and aspirations

How will the equipment assist the participant to undertake activities, so as to facilitate the participant’s social and economic participation?

How will the equipment represent value for money in that the costs of the support are reasonable, relative to both the benefits achieved and the cost of alternative support? (NB: Consider lower cost alternatives, therapy provision/hours, reduce the need for support worker hours, can the AT perform multiple purposes, can it change and adapt as the person’s needs change. etc.)

How will the equipment be, or likely to be, effective and beneficial for the participant, having regard to current good practice?

Risks (NDIS participants)

Please outline the potential risks or harms to the participant if the requested assistive technology is NOT approved by NDIA

Equipment Requested

Please list all the items required and provide all the information we need for ordering:

Acknowledgement Statement: Please read and sign

I/We, the undersigned, acknowledge and accept that equipment provided by the Electronic Communication Devices Scheme is provided under the following condition: the proper use and care of the equipment is the responsibility of the person to whom the item is provided. For repairs, please contact the Scheme on 9362 6111.

Signature of prescribing Occupational Therapist:

Name (please print)

Signature: Date: Click here to enter a date.

Occupational Therapy Application Checklist:

Non-NDIS participants:

1. ☐DHHS VA&EP Application Form
2. ☐Occupational Therapy Report completed and Acknowledgement Statement (pg 5) and Privacy Statement (pg 7) signed
3. ☐Letter or email from the individual or organisation indicating that they will pay the top-up amount. This is only required if the total cost of mounting & switches being requested (not including postage) is above $1500 (please note that $7000 in total is available from the ECDS in a calendar year for communication devices, of which $1500 can be used for mounting).

NDIS participants:

1. ☐Occupational Therapy Report completed and Acknowledgement Statement signed
2. ☐Quote(s) from approved suppliers

Ready to Submit?

Email: ; Fax: 9687 1607 or Post: PO Box 1235 ROBINSON 3019

Notes for Applicants:

VAEP: ECDS POLICY FOR NON-NDIS PARTICIPANTS:

• Current ceiling for mounting & switches is $1500, which is included within the total ceiling amount of $7000.
• ONE mount per client per calendar year - regardless of cost. Please consider carefully what to include in your application.
• If the cost of the equipment is above the total ceiling amount of $7000, not including postage/shipping, (e.g. communication device costs $6000 & mounting system costs $1400, gap is $400), written confirmation from the person or organisation who has agreed to pay the gap amount needs to be submitted to ECDS. Their current contact details need to be included. Suppliers will not process orders without this confirmation.

Please note that we need a letter or email FROM THE PERSON OR ORGANISATION WHO WILL BE PAYING THE TOP-UP FUNDS. A letter or email from the treating therapist indicating who will pay is not sufficient.

• Please note that ECDS does NOT fund generic devices (e.g. iPads, phones, Android tablets etc.) for non-NDIS participants. However we will fund a mounting system when these generic devices are being used as a communication system (for example, when using a communication app with the ipad).
• Two forms need to be completed: VAEP form + Occupational Therapy Report form
• A doctor’s signature to confirm disability is required for new applicants. If person is already on the ECDS database from a previous application, this signature is not required.
• As a DHHS requirement, 12 months after equipment is issued, we contact the prescribing occupational therapist or key contact person to review whether the device is being used and meeting the client’s needs

Applications for NDIS Participants:

• Please refer to the ‘Quick Guide: applying to ECDS for NDIS participants’ or contact ECDS for information about how to apply.

Privacy Notice

Privacy policy

The Electronic Communication Devices Scheme (ECDS) is a service of Yooralla. Yooralla has a privacy policy which tells you what:

• guides us when we collect personal information
• we must do before we can use or disclose personal information
• choices you have about giving us personal information
• rights you have to access and correct personal information
• rights you have to complain about our handling of your personal information.

Collection of your personal information:

In addition to the information you provide to ECDS, we may also need to seek further information from other organizations or individuals to assist us with processing this application or providingequipment services to you.

Use and disclosure of your personal information

ECDS will only use your personal information to decide your eligibility and to provide equipment services.

ECDSwill not use any of your personal information for other purposes, or disclose your personal information to any other organization or individual unless authorized or required by law or you provide consent for us to do so.

From time to time your information may be included in confidential internal and external audits to ensure that we continue to offer a high quality service to our clients.

Storage of your personal information

ECDStakes precautions to keep your personal information secure. We use password protected computers and locked filing cabinets located in a restricted access office.

More information: If you would like to know more about Yooralla’s privacy policy please visit our website or contact: Yooralla’s Privacy Officer, PO Box 238, Collins Street West VIC 8007.

Declaration

This declaration should be completed by the client or their authorized representative. Where this is not practical, this declaration may be completed by the prescribing health professional with the consent of the client or authorized representative.

☐Client or Authorized Representative: I understand the above privacy notice and consent to the collection, use and disclosure of my personal information as described.

OR

☐Prescribing Health Professional: I declare that I have discussed and explained the above privacy notice to my client or their authorized representative, AND that they consent to the collection, use and disclosure of their personal information as described.

Name: Signature:Date:Click here to enter a date.