LONG ISLAND TALKING BOOK LIBRARY

Return this form to: LITBL/Suffolk Cooperative Library System

627 North Sunrise Service Road

P.O. Box 9000

Bellport, New York 11713-9000

(631) 286-1600 (24 hours)

(866) 833-1122 (Toll-free for Nassau/Suffolk)

(631) 286-4546 (TTY for Hearing Impaired)

APPLICATION FOR FREE LIBRARY SERVICE FOR INSTITUTIONS

Institutions: Talking Books and talking book equipment for the use of blind and physically disabled persons who qualify may be loaned to institutions such as nursing homes and hospitas, for the use of such persons only.

Schools: The talking books and equipment may also be used in public or private schools where disabled students are enrolled; however, the students in public or private schools must be certified as eligible on an individual basis and must be the direct and only recipients of the material and equipment. Please complete the "Certification of Student Eligibility" form for this purpose.

Veterans: In the lending of books, recordings, playback equipment, musical scores, instructional texts, and other specialized materials, preference shall be given at all times to the needs of the blind and other physically disabled persons who have been honorably discharged from the armed forcesof the United States

Confidentiality: Records relating to the use of library materials which contain names or other personally indentifying details are confidential and will not be disclosed except upon request or consent of the user or when required by law.

Please print or type

Name of Institution ______________________________________________________

Address _______________________________________________________________

Village/Town _________________________ State ___________ Zip ______________

Telephone ____________________________

Name and title of staff member who will be responsible for this service:

_______________________________________________________________________

Number of persons unable to read or use standard printed material who will be served: ________

Type Of Institution: _____ Nursing Home _____ Hospital _____ Library _____School

___ Other (specify) ______________________________________________________

CRITERIA FOR ELIGIBILITY

Legal Blindness* (blind persons whose visual acuity, as determined by competent authority, *is 20/200 or less in the better eye with correcting lenses, or whose widest diameter of visual field subtends an angular distance no greater than 20 degrees).

Visual Impairment* (persons whose visual disability, with correction and regardless of optical measurement, is certified by competent authority* as preventing the reading of standard printed material).

Physical Disability* (persons certified by competent authority* as unable to read or unable to use standard printed material as a result of physical limitations).

Reading Disability** (persons certified by competent authority** as having a reading disability resulting from organic dysfunction and of sufficient severity to prevent their reading printed material in a normal manner).

Qualified readers must be residents of the United States, including the several states, territories, insular possessions, and the District of Columbia, or American citizens, domiciled abroad.

CRITERIA FOR CERTIFYING AUTHORITY

*In cases of blindness, visual disability, or physical limitation, “competent authority” is defined to include doctors of medicine; doctors of osteopathy; ophthalmologists; optometrists; registered nurses; therapists; professional staff of hospitals, institutions, and public or welfare agencies (e.g., social workers, case workers, counselors, rehabilitation teachers, and superintendents). In the absence of any of these, certification may be made by professional librarians or by any person whose competence under specific circumstances is acceptable to the Library of Congress.

**In the case of reading disability from organic dysfunction, “competent authority” is defined as doctors of medicine and doctors of osteopathy who may consult with colleagues in associated disciplines.

To be completed by certifying authority

I certify that the institution named serves persons who are unable to read or use standard printed material for one of the reasons specified above. I further certify that the reading materials and equipment borrowed will be used by such persons only.

Please Print or Type

Name _________________________________________________________________

Title/Occupation _________________________________________________________

Address _______________________________ Telephone _______________________

City _________________________________ State ________ Zip Code _____________

Signature __________________________________ Date ________________________

BOOKS AND MAGAZINES

You may borrow any of the following equipment. Please check those you wish to receive.

o Talking books on cassette

o Talking books on record

o Magazines on cassette

o Braille Materials provided from the Andrew Haskell Library for the Blind and Physically Handicapped

o Scores, instructions, and magazines about music in special media from the National Library Service for the Blind and Physically Handicapped. Individual applications must be submitted.

EQUIPMENT

You may borrow any of the following equipment. Please check those you wish to receive.

o Standard cassette player

o Standard record player

o Special equipment and accessories for readers with special needs (please specify)

o Easy Cassette Player - for individuals who have difficulty operating the standard cassette player, this machine is simpler to operate but also less versatile.

o C-80 Cassette Player - similiar to the standard cassette player, this machine feature a pitch-restoration device which is intended for individuals who need to cover a lot of material quickly.

o Combination Player - when available, this machine will combination all the features of the standard cassette player and the record player in a single unit; however, it will be somewhat heavier and more complex to operate than the seperate units.

o Lightweight Headphones - issued only to readers who require them in order to be able to listen to talking books, as in nursing homes and hospitals where loudspeakers are not permitted.

o Amplifier - for persons with a significant hearing loss (medical certification required)*

o Remore Control Unit - for persons confined to bed with difficulty in mobility, this device turns playback equipment on and off but will not control other functions such as volume and speed*

o Breath Switch - for persons with little or no use of their extremities, to be used in conjunction with the Remote Control Unit*

o Tone Arm Clip - for persons who have difficulty grasping the tone arm of the record player

o Extension Levers - for persons who have difficulty manipulating the key controls on the standard or C-80 cassette player.

o Pillowspeaker - for persons who are confined to bed, is placed under the reader's pillow and is normally heard only by the reader

*A seperate application form is required for these devices.

INFORMATIONAL MATERIAL

You will automatically receive catalogs of Talking Books, Talking Books Topics (a bi-monthly publication annoucing newly released books), and the LITBL handbook and newsletter. Please check here if you would also like any of these publications.

o Talking Books for Seniors (handbook for activity directors)

o Talking Books and Reading Disabilities

o Factsheet for Parents and Educators

DEPOSIT COLLECTION

Most institutions maintain deposit collections of talking books which are exchanged periodically for different titles. Please indicate the number of talking books (10-100) which you would like for a deposit collection: ___________

FREQUENCY OF SERVICE

o Most talking book users are on a "return" system whereby each time they return a talking book we send another. Please check here if you would like to receive books on this system.

o Please check appropriate line if you would prefer a different type of service:

o Weekly o Biweekly o Triweekly o Monthly.

o Indicate quantity you would like to receive on this basis: _______

o Please check here if you would like receive talking books only when you request them. (You must borrow at least one talking book per year from the LITBL in order to remain active in the program and continue to use the equipment that has been loaned to you. Recorded books borrowed from other agencies, such as textbooks borrowed from Recorded for the Blind & Dyslexic, do not count towards this mimimum.)

BOOK SELECTION (check one):

oSend only the specific titles I will request. Do not select books for me.

oThe library may select books for me based on the reading preferences checked below:

Reading Level:

oAdult

oYoung Adult

oChild (specify reading level ___________)

Check if you do not wish to receive books that contain:

oStrong Language

oViolence

oExplicit descriptions of sex

Primary Language:

oEnglish

oSpanish

oFrench

oItalian

oOther, please specify: _______________________

READING INTERESTS (check as many as apply):

FICTION

oAdventure oAnimal Stories oBestsellers oBlack Interests oChildren's Stories

oClassics oFamily Stories oGothic Novels oHistoric Novels oHumor

oJewish Interests oModern Novels oModern Novels/ Risque oMystery & Spy oOccult

oRomance oScience Fiction oShort Stories oWar Stories oWesterns

NON-FICTION

oAdventure oAbout Music oBestsellers oBiographies oBlack Interests oBusiness oCooking

oCurrent Events oDisabilites oEssay & Collections oFine Arts oHealth oHistory oHomemaking

oHumor oJewish Interests oOccult oPhilosophy oPlay oPoetry oPsychology

oPolitics&Government oReligion (specify) _______________ oScience oSports oTravel oWar

Please indicate any other type of books or favorite authors that interest you. Be as specific as possible. _____________________________________________________________________________________________

CERIFICATION OF STUDENT ELIGIBILITY

Public or private schools where disabled students are enrolled must submit a certification of elegibility for each applicant annually. Refer to Criteria for Eligibility to determine which students are eligible for talking book service, and who may serve as the certifying authority. Please note that students with reading disabilities who meet the criteria for eligibility must be certified by a doctor of medicine or a doctor of osteopathy.

This is to certify that the following student(s) is are unable to use standard printed material for the reason indicated:

Name and Address of Student(s)

Disability (Indicate blindness, visual impairment, physical disability, reading diability from organic dysfunction)

CERTIFYING AUTHORITY

Please Print or Type

Name _________________________________________________________________

Title/Occupation _________________________________________________________

Address _______________________________ Telephone _______________________

City _________________________________ State ________ Zip Code _____________

Signature __________________________________ Date ________________________