Illinois Care Connections - Request Form

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

* = required

Referring Agency

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

Referring Agency Point of Contact

Please complete the information below for the participant:

(The participant is the individual for whom the device is being requested. Please involve the participant in the collection of this data.)
Is the participant new to your agency?  

UCLA Loneliness Scale

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

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

Assistive Technology and Information Technology Options

The Illinois Care Connections Program offers access to assistive technology devices (AT) and durable medical equipment (DME) to assist older adults age 60+ in living more independently and safely. It is also intended to help them to be more connected to family, friends, access health providers and participate in recreational activities through technology.

Please select all the AT/DME device types the participant potentially needs to live as confidently and independently as possible:

AT


What is the main reason the participant needs a tablet device? (choose one)





Why does the participant need a vision device?

If participant currently uses vision device(s), describe device(s) used:

Why does the participant need a hearing device?
If participant currently uses hearing device(s), describe device(s) used:

DME


Why does the participant need a mobility device?
If participant currently uses mobility device(s), describe device(s) used:

Why does the participant need a speech communication device?
If participant currently uses speech communication device(s), describe device(s) used:

Why does the participant need aids for daily living?


If participant currently uses daily living device(s), describe device(s) used?
What is the main reason the participant needs environmental controls / smart home devices?

General Screening Questionnaire

Does the participant currently use a tablet type device?  
What kind of telephone does the participant use?  
Does the participant currently have Internet Access?  
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?  
Would the participant be able to participate in technical assistance via the following modalities: (check all that apply)


Please select the preferred language





Tablet Questionaire

Tablet Requested (please select one):

Applications Requested (check all that are needed):

Functional Assessment

Tablet Operation:
Cognitive/Memory – Will the participant be able to do sequential memory tasks for turning device on/off, navigating menus and activating applications (apps)?  
If no, how would you rate the participants’ cognitive/memory skills?      
Motor Skills/Dexterity – Will be able to find and manipulate buttons; can learn and perform gestures (i.e. tapping, swiping)?  
If no, how would you rate the participants’ motor/dexterity skills?      
Hearing – Will the participant be able to hear audio output of the device?  
If no, how would you rate the participants’ hearing/understanding speech?      
Vision – Will the participant be able to see and/or read the screen?

If unsure, how would you rate the participants’ vision/reading text skills?      

This program is funded by the Illinois Department on Aging

The Illinois Department on Aging does not discriminate in admission to programs or treatment of employment in programs or activities in compliance with appropriate State and Federal Statutes. If you feel you have been discriminated against call the Senior Helpline at 1-800-252-8966, 1888-206·1327 (TTY).