Assistive Technology

Pennsylvania's Assistive Technology Lending Library

DEVICE LOAN REQUEST FORM - STEP 1 of 3

Make sure you have added all of the devices you want to borrow (up to 5 at a time) to your "loan cart" BEFORE you begin this form. If you need to add additional items Continue to Browse our Equipment List.

If you are ready to Complete the Request Form: Fill out the form below, then click the "SAVE and Continue" button. Required fields are marked with a *

SECTION 1. Borrowing information: About the recipient (person who will be using the equipment):
Name *
If recipient is a minor, name of parent/guardian:
Daytime phone # *
Alternate phone #
Street Address *
Zip *
City *
State *
County *
E-mail
The recipient is: * Person w/ disability Family/Authorized Rep Employer/Employment service Educator/School/University/Student Health, allied health, rehabilitation provider Community Living Provider/Community Organization Other (specify)
First time borrowing a device? * Yes No
If the recipient is a person with a disability, please complete this section: Required items in this section only apply if the recipient is a person with a disability.
Date of Birth or Age: *
If the recipient is served by any of the following “systems”, (check all that apply): * Office of Mental Health Office of Mental Retardation Early Intervention Public School Private School Office of Vocational Rehabilitation Blindness and Visual Services Area Agency on Aging / Senior Center None Other (specify)
Race/Ethnicity: Caucasian African-American Asian Latino Other (specify)
The assistive technology device will MOSTLY help them: * at School at Home or in Community at Work using Phone or Computer
Reason for borrowing (check all that apply): * Device trial or evaluation (to find out what kind of device / if a device can help) Professional Development or Outreach - Date(s) needed: Accommodation (to use in work setting or during a public event) Served as loaner during device repair or while waiting for funding Other (specify)
Do you need instructions and the inventory sheet that comes with each item in an alternate format (large print, disk, audio tape, Braille)? Please specify

Inventory Code	Name of Item	Replacement Value
Equipment Requested: *CHECK boxes next to items that are required at the same time.*
You have not selected any devices to borrow. Please enter the information manually once you print the form.

How to borrow an item

Loan request forms

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Assistive Technology

DEVICE LOAN REQUEST FORM - STEP 1 of 3

SECTION 1. Borrowing information: About the recipient (person who will be using the equipment):

If the recipient is a person with a disability, please complete this section: Required items in this section only apply if the recipient is a person with a disability.

How to borrow an item Loan request forms

SECTION 1. Borrowing information:
About the recipient (person who will be using the equipment):

If the recipient is a person with a disability, please complete this section:
Required items in this section only apply if the recipient is a person with a disability.

How to borrow an item

Loan request forms