LBPD Application Form

Certificate of eligibility and
application for library service for individual

Please print, complete, and return this application in person, by U.S. Mail, or fax.

Mailing Address:
4135 Washtenaw Ave.
P.O. Box 8645
Ann Arbor, MI 48107-8645

Fax number:
(734) 973-4963

Washtenaw County Library for the Blind and Physically Disabled (LBPD) loans books and magazines in alternative format (audio cassette tape, large print and Braille) to individuals in Jackson, Livingston and Washtenaw Counties who are unable to read or use normal printed materials as a result of a physical disability. Washtenaw County LBPD is part of a network administered by the National Library Service (NLS) for the Blind and Physically Handicapped, Library of Congress, Washington, D.C. and the Library of Michigan Service for the Blind and Physically Handicapped, Lansing, MI.

Eligibility for Service

BLIND - persons whose visual acuity, as determined by competent authority, is 20/200 or less in the better eye with correcting lenses, or whose widest diameter of visual field subtends an angular distance no greater than 20 degrees.

DEAF-BLIND - persons with a severe auditory impairment in combination with legal blindness.

VISUALLY DISABLED - persons who lack visual acuity to read standard printed materials without aids or devices other than regular glasses.

PHYSICALLY DISABLED - persons who are unable to read or use standard printed materials as a result of physical disability. Examples include:

without arms or the use of arms
impaired or weakened muscle and nerve control
limitations resulting from strokes, cerebral palsy, multiple sclerosis, muscular dystrophy, polio, arthritis

READING DISABLED - persons whose reading disability is a result of an organic dysfunction of sufficient severity to prevent reading printed materials in a normal manner.

BY FEDERAL LAW, THIS DISABILITY REQUIRES THE SIGNATURE OF A DOCTOR OF MEDICINE OR OSTEOPATHY AS CERTIFYING AUTHORITY.

Certifying Authority

In cases of BLINDNESS, VISUAL or PHYSICAL DISABILITIES, "competent authority" is defined to include doctors of medicine and osteopathy, ophthalmologists, optometrists, registered nurses, therapists, professional staffs of hospitals, institutions and public welfare agencies (e.g. social workers, case workers, counselors, home teachers and superintendents. In the absence of any of these, certification may be made by professional librarians or by any person whose competence under specific circumstances is acceptable to NLS. NOTE: In case of READING DISABILITY from organic dysfunction, competent authority is defined as doctors of medicine or osteopathy ONLY, who may consult with colleagues in associated disciplines.

All patron records pertaining to this service will remain confidential in compliance with state and federal laws.

Please type or print. Return completed application to Washtenaw County LBPD.

TO BE COMPLETED BY CERTIFYING AUTHORITY

The individual named below is unable to read or use normal printed materials as a result of the following physical limitation (check one):

Blind

Deaf-Blind

Reading Disability

Visual Disability

Physical Disability

I certify that the applicant named has requested library service and is unable to read or use standard printed material for the reason indicated above.

Name of Certifying Authority		Date
Profession
Street Address		Telephone
City	State	Zip
Signature of Certifying Authority
Name of Applicant
First	M.I.	Last
Street Address		Telephone
City	State	Zip
Date of Birth		Sex
Alternate Contact Person		Telephone
Veterans, by Federal law, receive preference in obtaining books and equipment. Check here if you have been honorably discharged from the Armed Forces of the United States.

MATERIALS AVAILABLE

Check ALL materials wanted:

Books and Magazines Recorded on Cassette Tape and Standard Cassette Book Machine: Cassette tapes are recorded at a slower speed that is not compatible with commercial cassette equipment.

Large Print Books

Described Videos:Movies and television programs where the visual elements are described without interfering with the dialogue or sound effects.

Braille Books and Magazines:This service is provided directly from the Library of Michigan Service for the Blind and Physically Handicapped in Lansing.

SPECIAL ATTACHMENTS

Check items needed:

Extension Lever - assists physically disabled individuals to manipulate the function keys of the cassette machine.

*Amplifier/Headphone System - SOLELY for the use of severely hearing impaired individuals. (Requires signature of an audiologist.)

*Remote Control Unit - SOLELY for the use of persons confined to bed or with very limited mobility.

*Breath Switch - SOLELY for the use of severely physically impaired individuals.

*If you indicate a need for any of these attachments, appropriate application form(s) will be sent to you. These attachments are loaned directly to consumers from the Library of Congress.

CIRCULATION OF MATERIALS

Check ONE of the following:

Send books on a continuing basis. As each book is returned to the Library, it will be replaced with a new book;

Send books ONLY when requested.

RETURN OF EQUIPMENT AND MATERIALS

Books and equipment are loaned to eligible individuals who are registered with the Library. At least one recorded book or magazine must be borrowed within a twelve-month period. The equipment must be used in conjunction with recorded materials provided by the Library

MAGAZINES

Check here to receive a list of magazines which are available on cassette tape and in Braille to registered consumers at no charge.

CATALOGS OF NEW BOOK TITLES

Bi-monthly catalogs listing newly produced titles are mailed directly to registered consumers from the Library of Congress.

Check the publication desired and a corresponding format:

TALKING BOOK TOPICS	BRAILLE BOOK REVIEW
Large Print	Braille
Cassette	Cassette
	Braille

EXCLUSIONARY CRITERIA

Check below if you do not wish to receive books that contain:

Explicit descriptions of sex	Long books (4 cassettes or more)
Strong language	Violence

COMPREHENSION LEVEL

Check comprehension levels for materials you would like to receive (you may check more than one):

Juvenile Fiction	Young Adult Fiction	Adult Fiction
Juvenile Non-Fiction	Young Adult Non-Fiction	Adult Non-Fiction
K-3 4-6 6-9

READING INTERESTS

You are encouraged to select your own books but if you cannot, the Library will select books based on subjects of interest to you. Using the list below, check up to TEN subject areas of reading interest to you.

Adventure	Family Chronicle	Nature
Agatha Christie	Fantasy	Occult/Paranormal
Animals	Fine Arts	Oprah's Book Club
Autobiography/Biography	Folk/Fairy Tales	Philosophy
Aviation	Gardening	Pioneer/Frontier
Award Winners	Gay/Lesbian	Plays
Bestsellers	Gentle/Nostalgia	Poetry
Bible Stories	Handicapped	Politics-Foreign
Black America	Harlequin/Regency	Politics-US
Black Interests	Health	Psychology
Blindness	Historical Novel	Religion
Business	History	Science
Careers	Hobby/Craft	Science Fiction
Child Care	Holidays	Sea
Civil War	Humor	Shakespeare
Classics	Inspirational	Short Stories
Communication	Jewish Interests	Sports
Computers	LBPD Book Lovers Club	Spy/Espionage
Consumerism	Literary Criticism	Stage/Screen
Cooking	Louis L'Amour	Star Trek
Crime	Love Stories	Suspense
Current Events	Lusty Romance	Travel - Foreign
Danielle Steele	Medicine	Travel - U.S.
Diet/Nutrition	Music	UFO
Economics	Mystery-Deductive	War
Erotica	Mystery-Tough	Westerns
Essays	Native American	Women

Do you have favorite authors? List:

Any other subject area of interest to you?

Would you like books and/or magazines in a language other than English?
List language(s):

Is there anything else about your reading needs
that you would like to share with us?

Revised 6-6-01