Electronic Communication Devices Scheme

Equipment Application: Speech Pathology Report

Office use only:

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

1 Client / Participant Details

Title Choose an item.First name(s) Click here to enter first name.Surname Click here to enter surname.
Is the client an existing ECDS client? Yes ☐ No ☐ Don’t know ☐
Is the client an NDIS participant? Yes ☐ No ☐If yes, NDIS Participant Number:
DOB Click here to enter a date. Age Diagnosis Choose an item.
Diagnosis Detail (if ‘other’ selected):
Address Suburb Postcode
Phone Mobile Email
Next of kin /key support person(e.g. parent, spouse)
Name
Relationship
Phone
Email / NDIA Planner(if known)
Name
Phone
Email
NDIS Region
Speech Pathologist
Name
Organisation
Campus
Phone
Mobile
Email
Postal Address / Occupational Therapist
Name
Organisation
Campus
Email
Postal Address

______

Office Use Only

Device
Asset Number
Serial Number / Issued
Returned
Reason
Device
Asset Number
Serial Number / Issued
Returned
Reason
Device
Asset Number
Serial Number / Issued
Returned
Reason

Additional treating Speech Pathologist

Is another Speech Pathologist providing indirect or direct services to this client / participant?Yes ☐ No ☐

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

Contact details of additional Speech Pathologist

Name: Click here to enter text.Organisation: Click here to enter text.

Phone: Click here to enter text.

In the space below, please briefly describe the outcome of the collaboration including agreements regarding responsibility for device implementation and support:

Click here to enter text. /

Please ensure the additional Speech Pathologist signs the acknowledgement statement.

2 Background Information

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

Click here to enter text. /

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

Click here to enter text. /

Fine motor skills: e.g. Can the person press a key on a keyboard?

Click here to enter text. /

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

If ‘yes’, please provide details:

Click here to enter text. /

3 Current Communication

Briefly outline how the client/participant currently communicates. What communication strategies are used? Include informal and/or symbolic strategies, electronic devices etc.

Click here to enter text. /

What are the limitations of the person’s current communication strategies?

Click here to enter text. /

4 Communication Goals

List the client’s / participant’s communication goals relevant to this application.

What will this equipment or software enable the person to do?

Click here to enter text. /

5 Essential Features Required

List the essential features required in the device or software you are requesting. For example: switch access, large screen, durability, battery life, audible in noisy environments, supplier support etc.

Click here to enter text. /

6 Care of Equipment

In what locations or contexts will the person use the device/software?

Click here to enter text. /

What strategies will you put in place to reduce risk of damage to the equipment?

Click here to enter text. /

Does the person have behaviours of concern that may impact on care of equipment?Yes ☐ No ☐

If ‘yes’, please provide details:

Click here to enter text. /

7 Access and Positioning

(Skip this section if not relevant e.g. voice amplifier applications)

How will the person operate oraccess the device? Direct Touch ☐ Other☐Click here to enter text.

Where and how will the device be positioned for functional use?

Click here to enter text. /

Please note that if applying for an access peripheral (e.g. eye gaze system, head mouse, switch) or mounting system,a report from an occupational therapist is required. The OT Report Form can be downloaded from:

8 ComTECAssessment

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

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

Click here to enter text. /
This document is uncontrolled when printed, please refer to the Policies and Procedures Library for current controlled version
Policy Index: Customer/Electronic Communication Devices Scheme (ECDS) / Effective Date: 24/07/2017 (v15)
Responsible Manager: Kim Magee / Page 1 of 12
This document is uncontrolled when printed, please refer to the Policies and Procedures Library for current controlled version
Policy Index: Customer/Electronic Communication Devices Scheme (ECDS) / Effective Date: 24/07/2017 (v15)
Responsible Manager: Kim Magee / Page 1 of 12

9Exploration of Options

List ALL the devices, software and apps that you have trialled or considered. (Please don’t include non-tech strategies such as PECS or PODD/communication books here).

You may wish to refer to the ECDS Equipment Trial Guideline (2017) available on

Option
1 / Device / Software
Click here to enter text. / Cost
Click here to enter text.. / Trialled or considered??
Choose an item. / If trialled, specify trial length and location(s)
Click here to enter text. / If trialled, outline your observations and the trial outcome (e.g. operation of device, page navigation, communicative use etc.)
Click here to enter text.
Recommended: Y/N
Select Y/N / If YES, outline your rationale for recommendingthis option. Why is this the most suitable or appropriate option compared to alternatives?
Click here to enter text. / If NO, describe why this option is NOT considered suitable:
Click here to enter text.
Option
2 / Device / Software
Click here to enter text. / Cost
Click here to enter text. / Trialled or considered??
Choose an item. / If trialled, specify trial length and location(s)
Click here to enter text. / If trialled, outline your observations and the trial outcome (e.g. operation of device, page navigation, communicative use etc.)
Click here to enter text.
Recommended: Y/N
Select Y/N / If YES, outline your rationale for recommendingthis option. Why is this the most suitable or appropriate option compared to alternatives?
Click here to enter text. / If NO, describe why this option is NOT considered suitable:
Click here to enter text.
Option
3 / Device / Software
Click here to enter text. / Cost
Click here to enter text. / Trialled or considered??
Choose an item. / If trialled, specify trial length and location(s)
Click here to enter text. / If trialled, outline your observations and the trial outcome (e.g. operation of device, page navigation, communicative use etc.)
Click here to enter text.
Recommended: Y/N
Select Y/N / If YES, outline your rationale for recommendingthis option. Why is this the most suitable or appropriate option compared to alternatives?
Click here to enter text. / If NO, describe why this option is NOT considered suitable:
Click here to enter text.
Option 4 / Device/Software
Click here to enter text. / Cost
Click here to enter text. / Trialled or considered??
Choose an item. / If trialled, specify trial length and location(s)
Click here to enter text. / If trialled, outline your observations and the trial outcome (e.g. operation of device, page navigation, communicative use etc.)
Click here to enter text.
Recommended: Y/N
Select Y/N / If YES, outline your rationale for recommendingthis option. Why is this the most suitable or appropriate option compared to alternatives?
Click here to enter text. / If NO, describe why this option is NOT considered suitable:
Click here to enter text.
Option 5 / Device/Software
Click here to enter text. / Cost
Click here to enter text. / Trialled or considered??
Choose an item. / If trialled, specify trial length and location(s)
Click here to enter text. / If trialled, outline your observations and the trial outcome (e.g. operation of device, page navigation, communicative use etc.)
Click here to enter text.
Recommended: Y/N
Select Y/N / If YES, outline your rationale for recommendingthis option. Why is this the most suitable or appropriate option compared to alternatives?
Click here to enter text. / If NO, describe why this option is NOT considered suitable:
Click here to enter text.
This document is uncontrolled when printed, please refer to the Policies and Procedures Library for current controlled version
Policy Index: Customer/Electronic Communication Devices Scheme (ECDS) / Effective Date: 24/07/2017 (v15)
Responsible Manager: Kim Magee / Page 1 of 12

10 Client/Participant Feedback and Support

  1. Client / family response to device?

Click here to enter text. /
  1. Who will be responsible for setting up the device? Who will support the client and support team with learning to use the device, page design, vocabulary selection and modification, ongoing training in functional use of the device, reviews, device maintenance etc?

11 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.

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

Click here to enter text. /

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

Click here to enter text. /

c)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 including low tech AAC, therapy provision etc.)

Click here to enter text. /

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

Click here to enter text. /

12 Risks (NDIS participants)

Please outline the potential risks or harms to the participant if the requested equipment and/or software is NOT approved by NDIA

13Equipment Requested

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

(e.g. for a NOVAChat, please specify if you require a dedicated or non-dedicated device and type of software. If requesting akeyguard, please specify the type of keyguard and number and layout of cells required.)

Product Code / Item Description / Supplier / Cost
Product Code / Click here to enter item description. / Supplier / Cost /
Product Code / Click here to enter item description. / Supplier / Cost /
Product Code / Click here to enter item description. / Supplier / Cost /
Product Code / Click here to enter item description. / Supplier / Cost /
  1. Please provide a quote from an approved Australian supplier.
  1. Apps for Apple or Android devices

Applying for an app? Please double check the platform the client / participant will be using (Android or Apple) and take note of the following:

  • All apps will now be provided via iTunes gift vouchers (or Google Play gift cards). Gift vouchers will be sent to the prescribing speech pathologist who accepts responsibility for ensuring the requested apps are purchased and installed on the client or participant’s device.
  • It is NOT the responsibility of ECDS staff to assist clients, participants or families with redeeming or installing apps.
  • For Android apps, please ensure that the app you are requesting is compatible with the Android device that the client or participant will be using.

Device information session

If the client is not an NDIS participant, the ECD Scheme can provide a free 1:1 information session on the device for the speech pathologist.

  • The session is for the speech pathologist only
  • It’s a ‘train the trainer’ model - we donot provide small group training for clients / participants or support people.
  • If we are unable to provide a face to face session (e.g. due to distance) we will offer other options for you

Would you likeus to contact you to discuss training options? Yes ☐ No ☐

14Acknowledgement Statement: Please read and sign

I/We, the undersigned, acknowledge and accept that equipment provided by the Electronic Communication Devices Schemeis provided under the following conditions:

  1. 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. Do not send equipment to suppliers without prior authorisation.
  1. The Scheme is only able to provide support with simple troubleshooting in relation to the provided equipment or software.
  1. The Scheme is not responsible for: software installation or upgrades, hardware incompatibility, technical support, maintenance, licensing, or any additional software such as antivirus or word processing. The Scheme is also not responsible for mobile phone or internet fees.

Signature of prescribing Speech Pathologist:

Name (please print)

Signature: Date: Click here to enter a date.

………………………………………………………………… …………………………………

Signature ofadditional Speech Pathologist:

Name (please print)

Signature: Date: Click here to enter a date.

______

15 Privacy Notice: Please read and sign

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 organisations or individuals to assist us with processing this application or providing equipment services to you.

Use and disclosure of your personal information

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

ECDS will not use any of your personal information for other purposes. ECDS will not disclose your personal information to any other organisationor 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 client / participants.

Storage of your personal information

ECDS takes 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 / participant 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 / participant or authorized representative.

☐Client / participant 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 / participant 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.

16 Notes for Applicants:

Electronic Communication Devices Scheme policy for non-NDIS participants:

  • Ceiling is $7000
  • ONE device (or app/piece of software) per client / participant per calendar year - regardless of cost. For example, a Little Step by Step is considered one device. Please consider carefully what to include in your application.
  • If the cost of the equipment, not including postage/shipping, is above the ceiling amount, (e.g. device costs $7400), 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 Speech Pathologist indicating who will pay is not sufficient.

  • If additional items or accessories take the total amount above ceiling, please do not include these items in your application (e.g. device costs $6995 and the client / participant requires accessories to the value of $100). ECDS will not order the accessories.
  • Please note that ECDS does not fund generic devices (e.g. iPads, phones, Android tablets etc.) for non-NDIS participants.
  • The DHHS: VAEP form only needs to be submitted if the client / participanthas never applied to ECDS or SWEP before.
  • 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 prescribingSpeech Pathologist or key contact person to review whether the device is being used and meeting the client / participant’s needs

What will ECD Scheme fund or not fund for non-NDIS participants? (examples only)