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):

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E-mail






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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.

If the recipient is served by any of the following “systems”, (check all that apply): *














Reason for borrowing (check all that apply):



The assistive technology device will help: *


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

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How to borrow an item

Loan request forms


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