Sign language and oral interpreters, TTYs, and other auxiliary aids and services are available free of charge to people who are deaf or hard-of-hearing. For assistance, please contact any Hospital Personnel or the Information Office at _____________(voice/TTY), room ______.
These signs will include the international symbols for “interpreters” and “TTYs.”
To ensure effective communication with Patients and their Companions who are deaf or hard-of-hearing, we provide appropriate auxiliary aids and services free of charge, such as: sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with caption capability or closed caption decoders, and open and closed captioning of most Hospitals’ programs.
Please ask your nurse or other Hospital Personnel for assistance, or contact the Information Office at ______________ (voice or TTY), room _________________.
The Hospitals will also include in their Patient Handbooks a description of their complaint resolution mechanism.
If you recognize or have any reason to believe that a Patient or a relative, close friend, or Companion of a Patient is deaf or hard-of-hearing, you must advise the person that appropriate auxiliary aids and services, such as sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with captioning or closed caption decoders, and open and closed captioning of most hospital programs, will be provided free of charge when appropriate. If you are the responsible health care provider, you must ensure that such aids and services are provided when appropriate. All other personnel should direct that person to the appropriate ADA Administrator at _____________ and reachable at ________________.
The Hospitals will post this policy on the intranet within thirty (30) days of the Effective Date of this Agreement to all Hospital Personnel and both employed and affiliated physicians (physicians with practicing or admitting privileges), and to all new Hospital Personnel and newly employed or affiliated physicians upon their affiliation or employment with the Hospitals.
St. James will maintain records to document the information contained in the Compliance Report and will make them available, upon request, to the Department.
AGREED AND CONSENTED TO:
For Franciscan St. James Health:
ARNOLD KIMMEL, President
Franciscan St. James Health
1423 Chicago Road
Chicago Heights, Illinois 60411
For the United States of America
VANITA GUPTA, Acting Assistant Attorney General
EVE L. HILL
Deputy Assistant Attorney General
Civil Rights Division
REBECCA B. BOND, Chief
SHEILA M. FORAN, Special Legal Counsel
AMANDA MAISELS, Deputy Chief
PAULA N. RUBIN, Trial Attorney
Disability Rights Section
Civil Rights Division
U.S. Department of Justice
950 Pennsylvania Avenue, N.W.
Washington, D.C. 20530
Model Communication Assessment Form
We ask this information so we can communicate effectively with Patients and/or Companions. All communication aids and services are provided FREE OF CHARGE. If you need further assistance, please ask your nurse or other Hospital Personnel.
Name of Patient or Companion:
Nature of Disability:
Hard of Hearing
Relationship to Patient:
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)
Other. Explain: _________________
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)
Writing back and forth
Other. Explain: __________________
If the person with a disability, or the Patient who the person with a disability is with, is
ADMITTED to the hospital, which of the following should be provided in the patient room?
Video remote interpreting
Telephone handset amplifier
Telephone compatible with hearing aid
Flasher for incoming calls
Paper and pen for writing notes
Other. Explain: __________________________________
Please call _________(voice),_______________ (TTY), or visit us during normal business hours. We are located in room ____________________________