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Wisconsin Talking Book and Braille Library Related Links
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Certificate of Eligibility ApplicationWISCONSIN TALKING BOOK AND BRAILLE LIBRARY Certificate of Eligibility and Application for Library Services for Individuals Braille books and magazines, books and magazines recorded on cassette tape or disc, and audio-described videotapes are loaned to individuals who are unable to read or use normal printed materials as a result of blindness, visual disability or physical limitations. This CERTIFICATE OF ELIGIBILITY must be completed and signed by a competent authority OTHER than the applicant's immediate family. In cases of blindness, visual disability or physical limitations, "competent authority" is defined to include doctors of medicine and osteopathy, ophthalmologists, optometrists, registered nurses, therapists, professional staff of hospitals, institutions and public welfare agencies (such as social workers, case workers, counselors, rehabilitation teachers and superintendents). In the absence of any of these, certification may be made by a professional librarian or by any person whose competence under specific circumstances is acceptable to the National Library Service (NLS) for the Blind and Physically Handicapped, Library of Congress, Washington, DC. NLS administers the federal law under which the Wisconsin Regional Library for the Blind and Physically Handicapped operates. In the case of reading disability from organic dysfunction, competent authority is defined as doctors of medicine or osteopathy ONLY, who may consult with colleagues in associated disciplines. (Please print or type.) The above-named individual is unable to read or use normal printed materials as a result of the following physical limitation (see below for definitions).
_____Visual handicap In addition to any of the conditions above, does applicant also have a hearing impairment? If yes, indicate degree of hearing loss.
_____Moderate Definitions of Physical Limitations VISUAL HANDICAP: Lacks visual acuity to read standard printed materials without special aids or devices other than regular glasses. BLINDNESS: Visual acuity of 20/200 or less in the better eye with correcting glasses or the widest diameter of visual field subtending an angular distance no greater than 20 degrees. DEAF-BLIND: Severe auditory impairment in combination with legal blindness. PHYSICAL HANDICAP: Unable to hold a book or turn pages as a result of physical limitations. Examples include: without arms or the use of arms; impaired or weakened muscle and nerve control; limitations resulting from strokes, cerebral palsy, multiple sclerosis, muscular dystrophy, polio, arthritis, or similar conditions. READING DISABILITY: Organic dysfunction of sufficient severity to prevent reading printed materials in a normal manner. IF THIS DISABILITY IS CHECKED, A MEDICAL OR OSTEOPATHIC DOCTOR MUST SIGN. TO BE COMPLETED BY CERTIFYING AUTHORITY I certify that the Applicant named has requested library service and is unable to read or use standard printed material for the reason indicated above. (Please print or type.) In case we need to contact the Applicant but cannot, is there someone whom we can contact? (If the Applicant is a child, give parent's name.) Should we send your books to an address other than your residence? NO_____ YES _____ If "yes," where should we send them? NOTICE: All patron records pertaining to this service will remain confidential, but if you would like your name released to your local public library only in order to receive information, please initial here.______ BY LAW, PREFERENCE IN LENDING BOOKS AND EQUIPMENT IS GIVEN TO VETERANS. PLEASE CHECK HERE IF YOU HAVE BEEN HONORABLY DISCHARGED FROM THE ARMED FORCES OF THE UNITED STATES. _____ Have you ever used Talking Books before? NO _____ YES _____ Where?________________________ LANGUAGES: Will you borrow books in languages besides English? NO _____ YES _____ CHECK PREFERRED READING LEVEL:
K-3_____ 3-6_____ 6-9_____ Young Adult _____ Adult _____ WOULD YOU ACCEPT BOOKS WITH:
Strong Language? Yes_____ No_____ MATERIALS AVAILABLE (Please check materials wanted.)
_____*Standard Cassette Book Machine and books recorded on 4-track cassette tape. SPECIAL ATTACHMENTS (Please check only those items needed.)
_____*Extension levers--assist the physically handicapped in manipulating the function keys of a cassette book machine. (*NOT AVAILABLE DIRECTLY FROM THIS LIBRARY. These attachments are loaned from the Library of Congress. If you indicated a need for any of these attachments, the appropriate application forms will be sent to you.) RETURN OF EQUIPMENT Playback equipment and special attachments are supplied to eligible persons on extended loan. If this equipment is not being used in conjunction with recorded reading material provided by the Wisconsin Regional Library, it must be returned. CIRCULATION OF MATERIALS (Please check ONE of the following.) _____AUTOMATIC SELECTION: Send books on a continuing, rotating basis, by subject indicated below. As each book is returned to the Library, it will be replaced with a new book. OR _____BY REQUEST ONLY: Send only the specific titles I request. Do not select books for me. READING INTERESTS (Please check the subjects you want books chosen from. Do NOT check off the subjects if you wish to choose your own books.)
Other subjects of interest to you that we did not list: THE FOLLOWING BI-MONTHLY PUBLICATIONS LIST NEW BOOKS (Please indicate the one you want by checking the desired format.) TALKING BOOK TOPICS (Check one) in: Large Print_____ Cassette_____Computer Diskette_____ BRAILLE BOOK REVIEW (Check one) in: Large Print_____ Braille_____Computer Diskette_____ MAGAZINES: The Wisconsin Regional Library has a list of magazines which are available at no charge to registered patrons. The magazines are in Braille or recorded format. If you would like a copy of MAGAZINES IN SPECIAL MEDIA, check here_____. AUDIO-DESCRIBED VIDEOCASSETTES: You may request a list of audio-described videos, which can be played on a standard commercial VHS player. You may borrow one video at a time for one week only. If you would like a copy of the VIDEO CATALOG, check here_____. NFB-NEWSLINE SERVICE: Selected national & local newspapers & magazines, as well as time-sensitive announcements on the Wisconsin Information Channel, read over the telephone via a toll-free call. If you want to sign up for NEWSLINE, check here_________. PLEASE NOTE: Upon receipt, this application will be processed as soon as possible. However, please allow approximately one month's time before you receive the special equipment, accessories and books. Within that time period, you will receive a packet containing the "Handbook for Borrowers," catalogs and other important information with specific details of how to order and receive the items you wish to borrow. Questions? Phone us at 1-800-242-8822 or, in Milwaukee, 286-3045.
Last updated on 11/5/2009 11:07:41 AM |
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State Superintendent of Public Instruction Tony Evers
Department of Public Instruction, 125 S. Webster Street, P.O. Box 7841, Madison, WI 53707-7841 (800) 441-4563 DPI Home  About Us
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