Alaska Relay's Telecommunications Equipment and Tablet Distribution Program, administered by Assistive Technology of Alaska (ATLA), provides amplified phones, tablets with apps, TTYs and signalers to Alaska residents who need help with distance communication. This one-page form is the professional's certification that the applicant's hearing or speech impairment creates a barrier to distance communication. It goes to ATLA with the program application.
The applicant fills in only their name and phone type (text, voice or videophone). Everything else is completed by the certifier: agency, address, profession, the identified need (deaf, hard of hearing or severe speech disability), signature, printed name and date.
Download the current version from the source each time; forms change without notice.
Alaska Relay Telecommunications Equipment and Tablet Distribution Program Professional Certification Form
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The form lists five certifiers: a licensed physician, a certified audiologist or hearing-aid specialist, a certified speech-language pathologist, a Division of Vocational Rehabilitation counselor, or a special education teacher. The certifier checks their job, gives their agency and address, and signs and dates the form.
That, in their professional opinion, the applicant has a hearing or speech impairment that causes a barrier to accessing distance communication, and which need applies: deaf, hard of hearing, or severe speech disability. Alaska Relay also requires the applicant to be an Alaska resident.
Yes. Applicants can ask the ATLA team for help completing the forms or download them from Alaska Relay's TEDP page. After the forms and proof of residency arrive, ATLA contacts the applicant for an interview to match equipment to their communication needs.