Settlement Agreement between the United States of America and Columbia, SC Police Department - Exhibit C
SETTLEMENT AGREEMENT BETWEEN
THE DEPARTMENT OF JUSTICE
AND
THE CITY OF COLUMBIA, SOUTH CAROLINA POLICE DEPARTMENT
UNDER THE AMERICANS WITH DISABILITIES ACT

Exhibit C
Model Communication Assessment Form

We ask this information so we can communicate effectively with Arrestees and/or Companions. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask [Arresting Officer, Desk Sergeant, or other Police Department Personnel.

Date:

Name of Arrestee or Companion:

Nature of Disability:

 Deaf

 Hard of Hearing

 Speech Impairment

 Other: __________________

 Relationship to Arrestee:

 Self

 Family member

 Friend

 Other: ________________

 

Does the person with a disability want an onsite professional sign language or oral interpreter?

 Yes. Choose one (free of charge):

 American Sign Language (ASL)

 Signed English

 Oral interpreter

 Other. Explain: _________________

 No.

Which of the following would be helpful for the person with a disability? (free of charge)

 TTY/TDD (text telephone)

 Assistive listening device (sound amplifier)

 Qualified note-takers

 Writing back and forth

 Other. Explain: __________________

If the person with a disability, or the Arrestee who the person with a disability is with, is

IN CUSTODY, which of the following should be provided for communication with Police Personnel, Family/Companion, and attorney?

 Video remote interpreting 

 Telephone handset amplifier

 Telephone compatible with hearing aid

 TTY/TDD

 Flasher for incoming calls

 Paper and pen for writing notes

 Other. Explain: __________________________________

Any questions?