Illinois Care Connects

Requests can only be made by an authorized agency with a valid Agency Code

* = required

Referring Agency

Referring Agency Code

Participant Receives services or supports through the:

Community Care Program

MCO

Participants must be individuals receiving services, have an open case or participate in one of the following Older Adult Services programs/services:

Title 3: C1 (nutrition providers), C2 (home delivered meals), 3D (health education and promotion), 3E (caregiver support)

Title 7: legal services, open Adult Protective Services case, Long Term Care Ombudsman case/engagement

Participating/enrolled in a program that is funding from the AAA 'Social isolation grant funding' (i.e. friendly visitor/calling; memory cafes)

Referring Agency Name

Referring Agency Point of Contact

First Name

Last Name

Address Line 1

Address Line 2

State

County

City

Zip

Phone Number

Email Address

Please complete the information below for the participant:

(The participant is the individual for whom the device is being requested)

Is the participant new to your agency? Yes No

First Name

Last Name

Address Line 1

Address Line 2:

State

County

City

Zip

Phone Number (landline):

Phone Number (mobile):

Alternate Phone Number (Family, Friend, Support Staff):

Email Address:

Age

Gender

Race

Ethnicity

Sexual Orientation

General Information: Potential participants must have a genuine interest in using the device to maintain and/or increase their options for communication and social interactions with others. The referring provider must assess the potential participant using the UCLA-3 Item Loneliness Scale. The three questions below measure three dimensions of loneliness: relational connectedness, social connectedness and self–perceived isolation.

The responses to the questions will be scored as follows:
Response	Score
Hardly Ever	1
Some of the Time	2
Often	3

1. How often does the participant feel that they lack companionship?

2. How often does the participant feel left out?

3. How often does the participant feel isolated from others?

The score for each individual question is tallied together to give you a possible range of scores from 3 to 9.

Total Score:

General Screening Questionnaire

What is the main reason for participant being referred? (choose one) Communicate with family/friends
Purchase food and other household items
Telehealth Appointments
Recreation
Other (please specify)

Does the participant currently use a tablet type device? Yes No

What kind of telephone does the participant use? Landline Mobile (Cell)

Does the participant currently have Internet Access? Yes No

Is there someone in the home or who otherwise is available to assist the participant with technical problems like resetting internet, rebooting or troubleshooting electronic equipment? Yes No

Functional Assessment

Participant's Disability:

Cognitive/Memory – Will the participant be able to do sequential memory tasks for turning device on/off, navigating menus and activating applications (apps)? Yes No

If no, how would you rate the participants’ cognitive/memory skills? Poor Somewhat Limited Good Unsure

Motor Skills/Dexterity – Will be able to find and manipulate buttons; can learn and perform gestures (i.e. tapping, swiping)? Yes No

If no, how would you rate the participants’ motor/dexterity skills? Poor Somewhat Limited Good Unsure

Hearing – Will the participant be able to hear audio output of the device? Yes No

If no, how would you rate the participants’ hearing/understanding speech? Poor Somewhat Limited Good Unsure

Vision – Will the participant be able to see and/or read the screen? With magnification
Without magnification
Unsure

If unsure, how would you rate the participants’ vision/reading text skills? Poor Somewhat Limited Good Unsure

Please describe any other functional limitations that could impact the participant’s ability to use equipment provided to reduce social isolation.

Assistive Technology and Information Technology Options

Hardware (please select one): iPad with case/stand, headphone and keyboard
Android Tablet with case/stand, headphone and keyboard
Not Sure which device will best meet the participants needs

Applications

Applications (check all that are needed):

Apps for Connecting with Family and Friends: (iPad’s and Android Tablets will have Facetime, Google Hangouts, and or Zoom)

Internet Access (12 months of service provided and then participant is responsible for assuming cost)

Other Assistive Technology Devices

In case other funding becomes available please provide information about other Assistive Technology Devices the participant may need to help alleviate social isolation and maintain safety and independence in their home.

This program is funded by the Illinois Department on Aging