Illinois Care Connects

*PLEASE NOTE: THE MAXIMUM NUMBER OF REQUESTS FOR EQUIPMENT FROM THE ILLINOIS CARE CONNECTIONS PROJECT HAS BEEN REACHED. THANK YOU.*

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

* = required

Referring Agency

Referring Agency Code

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

Notice: The Device Bundle will be shipped via UPS with a signature required. Will the participant be able to sign for the package? * Yes No

If no, is there an alternate address where the device can be shipped with signature requirement? Yes No

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) Social Isolation
Communicate with family/friends
Purchase food and other household items
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

Would the participant be able to participate in technical assistance via the following modalities: (check all that apply) Phone
Webinar
Written instructions (paper or via email)

Functional Assessment

Paricipants 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

Hardware, Software and Support

Hardware

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

Accommodations

Possible Accommodations (check all that are needed): Siri Support (iPad Only)
External Keyboard
VoiceOver Directions – VoiceOver is an app that provids text to speech options (iPad Only)
Step by Step Written Instructions (alternate language)
Step by Step Written Instructions (Braille)
Step by Step Written Instructions (Large Print)
Headphones
Other (please specify)

This program is funded by the Department of Health and Human Services, Administration for Community Living, Grant No. 90NWC30043-01-00

Illinois CARE Connections