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The purpose of this pamphlet is to provide practical, cost-effective solutions concerning access to services and facilities by your patients who are blind, deaf-blind, or visually impaired. The intended audience for this pamphlet is providers who operate professional offices and administrators of other facilities, such as hospitals and nursing homes, that are places of public accommodation covered by Title III of the ADA. This pamphlet also contains information that is relevant to publicly owned or
operated health care institutions covered by Title II of the ADA.

NOTE: [In addition to your obligations as a place of public accommodation, you may also have certain obligations regarding
employment covered by Title I of the ADA. If you need information regarding employment, you should contact the Equal Employment Opportunity Commission (EEOC) for further information. The EEOC's address and phone number are contained in the resource list.]

Although the information contained in this pamphlet is targeted to administrators and service providers, many of the issues addressed (such as access to written documents; handling of currency; sighted guide technique; and awareness of and sensitivity to the needs of persons who are blind, deaf-blind, or visually impaired) are also applicable to other places of public accommodation, such as hotels, retail establishments, restaurants, and museums.

Accessibility checklists provided in this pamphlet illustrate methods of eliminating communications barriers to access to your
services and facilities. Most of the accommodations listed on the checklist are not structural in nature and thus will involve
minimal cost. The questions and answers contained in this pamphlet, together with the explanatory notes at the end of each checklist, illustrate and suggest some methods to remove or minimize barriers faced by your patients who are blind, deaf-blind, or visually impaired.

Consider this situation. A hospital employee, without identifying herself or the reason for her visit, enters the room of a patient
who is blind and noisily places an object on the patient's bedside table. Is it the patient's lunch or is it a procedure tray?
Solution: The employee should identify herself and her purpose for entering the room: "Good afternoon, I'm Carla Smith, a dietary aide. I've placed your lunch tray on your bedside table. It's a cold roast beef sandwich today with a green salad, cake, and coffee. Do you need any other information about your tray?" The ADA is a civil rights law signed by President Bush on July 26, 1990. The law mandates that individuals with disabilities shall have access to jobs, public accommodations, government services, public transportation, telecommunications--in short, participation in, and full access to, all aspects of society. The law is designed to be flexible in the way which businesses can comply with ADA requirements and further recognizes that certain accommodations may be too costly or burdensome for a particular business.

The ADA was designed to ensure that individuals with disabilities are afforded an equal opportunity to participate in all aspects of society. At the same time, the law recognizes the potential burdens placed on business to provide such access and further recognizes that what is an undue burden for a large metropolitan hospital is different from what constitutes an undue burden for the office of a provider in a small, rural setting. Health care providers are required to provide effective communication through appropriate auxiliary aids and services unless doing so would constitute an undue burden or would fundamentally alter the nature of the services provided.

Although most of the solutions suggested in these pages should involve little difficulty or expense, it is impossible to predict
whether a given accommodation will represent an undue burden in some instances or whether a structural modification is readily
achievable in light of your particular circumstances. This pamphlet will help you to examine all of your services and facilities to
identify barriers faced by your patients who are blind, deaf-blind, or visually impaired and will suggest solutions to many barriers along the way, but the most important solutions will often be suggested by your own patients.

The simple question: "How can I be of assistance to you, Mr. Clark?" is one of the most powerful ADA compliance tools.

A pamphlet cannot address every barrier to access in your health care setting. Rather, through a series of checklists, we will guide you through a process of examining your facilities and services, identifying possible barriers to access faced by persons who are blind, deaf-blind or visually impaired. We will recommend methods to identify possible solutions to these barriers. Not every patient will experience each of the barriers addressed in the checklists, and you may find solutions that are not listed on the checklists. In addition, some patients will not want or need a particular accommodation. Accordingly, if you are in doubt about what accommodation might be needed by a patient who is blind, deaf-blind, or visually impaired, simply ask. If the response is a refusal of assistance or of a particular accommodation, the law requires you to respect the patient's wishes in this regard. If your patient requests assistance, let him or her guide you, if possible, in the most effective way of responding to his or her request.

If you have already given some thought to access, examined your services and facilities, identified barriers, and implemented
solutions, such as some or all of the options suggested in this pamphlet, you will be well on your way to complying with the ADA.

Are hospitals, nursing homes, day-care centers, or professional offices of a health care provider covered by the ADA? Yes. If the entity is private and owns, leases, leases to, or operates a place of public accommodation, it is covered by Title III of the ADA. Places such as hospitals, nursing homes, day-care centers, ambulatory treatment or diagnostic centers, and professional offices of health care providers are all places of public accommodation covered by the ADA. In addition, hospitals or other health care institutions that are operated by state or local governments are covered under Title II of the ADA. This pamphlet
will focus on Title III obligations that are similar but not identical to those under Title II.

You keep referring to persons who are "blind, deaf-blind, or visually impaired." What do you mean by this? Why this distinction? When most people think of a person who is blind, they usually make three assumptions:

1. that the person will be totally blind,
2. that the person will use braille, and
3. that the person will travel with a cane or dog.

Your patient may fit all these assumptions. However, these assumptions are not true for most individuals who are "blind."
Roughly three-quarters of the population who are "blind" are not totally blind, i.e., they have some residual vision. Similarly,
most persons who are deaf-blind have some usable vision. Some persons who are blind, deaf-blind, or visually impaired may use braille, some may use a cane, others may use a dog, and still others may not use braille or a mobility aid at all. Thus, your
patient who is visually impaired may be a person with a hidden disability.

In addition, demographic data indicate that a significant number of individuals with vision loss are elderly and frequently experience multiple disabling conditions and that this number is growing rapidly. Also, there is a growing number of children with vision loss who also have additional disabilities.

There is a tremendous variability in how persons who are blind, deaf-blind, or visually impaired respond to their vision loss. This variability depends on how different eye conditions influence the affected person's vision, together with such factors as the length of time the person has experienced vision loss, intelligence, illness, the concomitant effect of multiple disabilities, or emotional stability. Some individuals who are visually impaired can see primarily in the periphery of their visual field_as if the center of their vision were blocked. Others can see only in the central portion of their visual field_as if looking through a tunnel. Still others see somewhat in all sectors of their visual field, but what they see is distorted or blurred in some way. This variability obviously has implications for how the person in question uses his or her remaining vision.

Many persons who are visually impaired function best under specific lighting conditions. Most often, direct lighting that does not
produce glare or shadows makes it easier for such persons to perform tasks. It is important to realize that too much light
produced from reflective interior surfaces, large windowed walls, spotlights, or certain paper coatings may create problems due to glare. Finally, many people who are visually impaired use hand-held magnifiers or more sophisticated visual aids, such as stationary or portable closed circuit-television magnification systems for reading printed material, bioptic lenses, or telescopes.

What does this all mean to the health care administrator or caregiver?

Don't make assumptions about your patient's visual acuity or the functional effects associated with his or her vision loss. The same person may have perfectly adequate travel vision during the day but may find mobility to be much more difficult at night under low lighting conditions. Respond to your patient's needs on an individual basis. As a general matter, be guided by his or her request for assistance. Thus, you may be asked by a patient who is visually impaired for guide assistance or for assistance in reading her bill, even though she may not use a dog or a cane. Similarly, a person who is visually impaired may request an additional lamp in the room. A patient who is blind may ask for assistance in completing menu choices or may ask the volunteer from the library to read a list of books available on cassette. If, on the other hand, it appears that the patient's limited experience with vision loss, illness, multiple disabilities, emotional stability, or intelligence is such that self-direction is difficult, explore options for providing accommodations while maintaining the individual's personal control and dignity.

In general, what must I do for patients who are blind, deaf- blind, or visually impaired to comply with Title III of the ADA?
Generally speaking, public accommodations such as hospitals, nursing homes, day-care centers, or other health care service
providers must ensure that patients who are blind, deaf-blind, or visually impaired have an equal opportunity to participate in and benefit from all of the goods and services provided by your facility. This may mean that you must modify your policies or
procedures, eliminate discriminatory eligibility criteria, provide auxiliary aids and services, and-or take steps to remove structural communication barriers in existing facilities. Auxiliary aids and services include, but are not limited to, readers, taped texts,
braille materials, and the acquisition or modification of equipment.

Are individuals other than patients also protected by the ADA?

Yes. It is not always the patient who requires auxiliary aids or services. For example, if a parent who is blind is required to
grant consent for his or her child's surgery, the contents of the consent form must be communicated effectively to the blind parent. In most cases, this can be accomplished by reading the consent form or by providing the form in braille or on audio cassette.

Are tax credits available to health care providers for the costs of providing auxiliary aids and services?

Yes. Businesses, including health care providers, may claim a tax credit of up to 50 percent of eligible access expenditures over
$250, but less than $10,250 per tax year. Eligible access expenditures include the costs of providing tactile interpreters,
readers, braille or recorded material, and other auxiliary aids and services.

How do I tell whether my services and facilities are accessible to and usable by persons who are blind, deaf-blind, or visually
impaired?

Unless your institution is operated by a state or local government and is thereby covered by Title II of the ADA, the law does not require places of public accommodation to conduct self-evaluations or to develop barrier removal plans. However, a self-evaluation and a barrier removal plan are the most effective ways to determine how accessible your services and facilities are now and what steps you need to take to provide greater accessibility in the future. Start with the barriers elimination checklists in this pamphlet. Each module applies to a particular function or department in your facility_admitting/financial services, medical services, environmental services and facilities, gift shop/cafeteria/public areas, discharge planning/home care, and the professional office of a health care provider. Each checklist section was designed as a stand-alone module that can be photocopied for use by the appropriate function or department within your facility. The explanatory notes section is designed for use with all checklists.

A self-evaluation includes identifying barriers to access within each function or department of your facility, evaluating how the
barrier is currently being addressed, if at all, and then identifying the range of solutions available that will eliminate or minimize the barrier. Is your current response to the barrier adequate, or must you do more? Which solutions are effective, least
expensive, or easiest to implement?

The ADA permits you to choose among competing methods of barrier removal, as long as the method chosen is effective. You may choose the least expensive solution, as long as it is effective. Once barriers are identified and solutions determined, you should then develop a plan for implementation. Not every barrier to access can be eliminated immediately. If it is determined that employee or staff training curricula must be modified, when will this be accomplished? If funds must be expended to acquire equipment or otherwise remove a particular barrier, when will this be done? Title III of the ADA does not require you to undergo a self-evaluation or to develop an implementation plan. If your time frames are reasonable and solutions effective, your good-faith effort to comply with the ADA will be an important factor in your favor in any proceeding to adjudicate a complaint against you. If you need help with the process of self-evaluation and development of an implementation plan, it is a good idea to contact one or more of the advocacy organizations or federal departments or agencies shown in the resource list. Assistance from organizations of and for persons who are blind as well as qualified individuals who are blind, deaf-blind, or visually impaired can be an invaluable resource in your efforts to comply with the ADA.

For additional solutions not covered in this pamphlet or for more detailed information than what we provide here, you should consult with the organizations and federal departments or agencies indicated in the resource list. You may also wish to obtain copies of the Title III regulations and the Title III Technical Assistance Manual published by the U.S. Department of Justice (see resource list for address).

Admitting and Financial Services

Staff affected: admitting staff, business office staff, volunteers

__ identifying personnel [1]
__ reading and completing admission forms and consents [2]
__ communicating contents of in-room documents, e.g., patient
   information brochures and hospital services directory [2]
__ reviewing hospital bill [2]
__ counting and identifying currency [3]
__ handing credit card to patient after imprint [3]
__ using signature guide or template [3]
__ using basic sighted guide and mobility techniques [4]
__ verbalizing directions [5]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to patient in a conversational manner and not
   through companion [6]
__ communicating with a person who is deaf-blind (including
   obtaining a tactile interpreter, if required) [7]
__ reviewing policy concerning admission of dog guides [8]
 

EVALUATION AND PROGRESS NOTES:

Medical Services

Staff affected: doctors, nurses, nurse's aides, orderlies, laboratory and respiratory services aides, x-ray technicians, other
allied service personnel, and volunteers

__ identifying personnel [1]
__ reading patient's mail [2]
__ communicating information, such as titles of books on library
   cart or items on gift shop cart [2]
__ using basic sighted guide and mobility techniques [4]
__ verbalizing directions [5]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to patient in a conversational manner and not
   through companion [6]
__ communicating with a person who is deaf-blind (including
   obtaining a tactile interpreter, when required) [7]
__ reviewing policy concerning admission of dog guides [8]
__ identifying patient's visual functioning [9]
__ furnishing TDD, upon request, for a patient who is deaf-blind [10]
__ verbalizing or demonstrating procedures before they are
   performed [11]
__ choosing treatment options that are appropriate to the patient's
   life-style as a person who is blind, deaf-blind, or visually
   impaired [12]
__ identifying medication [13]
__ assisting with feeding, toileting, bathing, or dressing (only if
   required and if such assistance is also provided to patients
   without disabilities)

EVALUATION AND PROGRESS NOTES:

__ orienting patient to layout of room, restroom facilities,
   convenience items, location and operation of call button,
   telephone, television, and environmental controls
__ orienting patient to treatment room and supplies, e.g., location
   of gowns and specimen cups
__ orienting patient to lounges, recreation rooms, and nursing
   station in relationship to patient's room
__ communicating evacuation/rescue plans; orientation to fire alarm
   pull boxes, fire extinguisher, and emergency exits
__ training in self-care and use of medical equipment

EVALUATION AND PROGRESS NOTES:

Dietary Services

Staff affected: dieticians; dietary aides; and, as appropriate, nursing staff and volunteers

__ identifying personnel [1]
__ communicating contents of written diets or menu plans [2]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to patient in a conversational manner and not
   through companion [6]
__ communicating with a person who is deaf-blind [7]
__ informing patient of arrival of food [14]
__ completing menus [14]
__ identifying location of food and utensils on tray [14]
__ assisting with preparation or cutting of some food items [14]
__ feeding (only if required and if such assistance is also
   provided to patients without disabilities) [14]

EVALUATION AND PROGRESS NOTES:

Environmental Services and Facilities

Staff affected: housekeeping; engineering; maintenance staff; security personnel; volunteers; and, as appropriate, architects and
designers of new facilities

__ identifying personnel [1]
__ using basic sighted guide and mobility techniques [4]
__ verbalizing directions [5]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to patient in a conversational manner and not
   through companion [6]
__ furnishing TDD, upon request, for a patient who is deaf-blind [10]
__ installing accessible signage meeting ADAAG requirements [15]
__ installing or modifying stairs, escalators, and elevators that
   meet ADAAG standards [15]
__ removing or protecting protruding objects, e.g., telephones,
   ashtrays, and drinking fountains, in accordance with ADAAG
   standards [15]
__ orienting patients and-or visitors to common areas ( e.g.,
   visitors' lounge, classrooms, cafeteria, cashier's office, and gift
   shop)
__ communicating evacuation/rescue plans; orientating to fire alarm
   pull boxes, fire extinguishers, and emergency exits
__ controlling environmental white noise, such as that created by
   velocity of water in fountains, which may mask environmental sound
   clues that are used by persons who are blind or visually impaired
   as aids to orientation and mobility [16]
__ providing adequate lighting and control of glare in patients'
   rooms and common areas [16]

EVALUATION AND PROGRESS NOTES:

Discharge and Home Care Services

Staff affected: discharge planners; social service staff; and, as appropriate, doctors, dieticians, and home care staff

__ identifying personnel [1]
__ communicating written information (e.g., home care instructions,
   medication names and dosages, follow-up appointments, etc.) [2]
__ using signature guides or templates [3]
__ using basic sighted guide and mobility techniques [4]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to patient in a conversational manner and not
   through companion [6]
__ communicating with a person who is deaf-blind (including
   obtaining a tactile interpreter, if required) [7]
__ customizing discharge plan to patient's life-style as a person
   who is blind, deaf-blind, or visually impaired [12]
__ identifying medication bottles and containers [13]
__ identifying appropriate community-based programs, when
   necessary, e.g., rehabilitation agencies and local agencies for
   blind people [17]
__ training in self-care (including operation of medical equipment)

EVALUATION AND PROGRESS NOTES:

Cafeteria/gift shop/public areas

Staff affected: reception desk staff; gift shop staff; business office staff; cafeteria staff; volunteers, security personnel; and,
as appropriate, nursing staff

__ identifying personnel [1]
__ reading price, size, and other product information [2]
__ counting and identifying currency [3]
__ handing credit card to customer after imprint [3]
__ using signature guide or template [3]
__ using basic sighted guide and mobility techniques [4]
__ verbalizing directions [5]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to visitor in a conversational manner and not
   through companion [6]
__ communicating with a person who is deaf-blind [7]
__ reviewing policy concerning admission of dog guides [8]
__ identifying and orienting visitors to dog guide relief area [8]
__ communicating contents of cafeteria menu [14]
__ providing assistance in locating table in cafeteria [14]
__ assisting customer in retrieving items from shelves
__ describing colors, patterns, and other visual characteristics

EVALUATION AND PROGRESS NOTES:

Professional Office of a Health Care Provider

(See checklist on environmental services and facilities for issues that may also apply to a professional office of a health care
provider.) If the office is leased space in an office building, both the landlord and the tenant are responsible to ensure that a blind, deaf-blind, or visually impaired person has full access to the services of the health care provider. As between the tenant and the landlord, the parties may allocate this responsibility in their lease agreement. For example, the landlord can assume
responsibility for the lobby, elevators, and other common areas in the office building, and the tenant can assume responsibility for access within the suite.

Staff affected: doctors, physician's assistants, nursing staff, reception staff, business/financial staff

__ identifying personnel [1]
__ reading and completing consent forms [2]
__ completing initial history [2]
__ reviewing bill [2]
__ communicating written information (e.g., home care instructions,
   medication names and dosages, and follow-up appointments [2]
__ counting and identifying currency [3]
__ handing credit card to patient after imprint [3]
__ using signature guide or template [3]
__ using basic sighted guide and mobility techniques [4]
__ verbalizing directions [5]
__ using disability-sensitive language and etiquette [6]
__ speaking directly to patient in a conversational manner and not
   through companion [6]
__ communicating with a person who is deaf-blind (including
   obtaining a tactile interpreter, if required) [7]
__ verbalizing or demonstrating procedures before they are
   performed [11]
__ identifying medication bottles and containers [13]
__ escorting patient to and from examining room
__ orienting patient to examining room and supplies, e.g., location
   of gowns and specimen cups
__ orienting patient to lavatory
__ communicating other important information, e.g., a phone access
   system at entry to the building or on-going construction in a
   common area of building

EVALUATION AND PROGRESS NOTES:

Explanatory Notes

 [1] Identifying personnel. Staff should initiate an introduction to a patient who is blind, deaf-blind, or visually impaired by
addressing the patient by name. They should always identify themselves by name and function and the reason they are there.
("Good morning, Mrs. Green. I'm Mr. Upshaw from the Physical Therapy Department. I'm here to show you some exercises your doctor ordered for you.") Name badges or uniforms may not be seen by a patient who is visually impaired.

 [2] Reviewing documents. Staff should read fully, upon request, and provide assistance, if necessary, in completing consent forms, financial responsibility forms, advance directive forms, bills, menus, and other documents. You may find it more helpful to your patient to provide frequently used or important documents_such as advance directive forms, consent forms, and financial
responsibility forms_in braille, large print, or on tape. The ADA requires that the contents of written material must be effectively
communicated to a person who cannot read printed material. In many situations, this requirement can be satisfied by providing a staff person to read the document while maintaining the patient's right to privacy (e.g., assistance in completing medical histories or financial forms should not be provided in the waiting room or other public area). The ADA requires that any mode of communication chosen be effective, which is determined on a case by case basis. Thus, for example, unless a tactile interpreter is present, braille may be the only effective form of communicating written material to a person who is deaf-blind.

 [3] Counting and identifying currency; credit cards; signatures. When handing currency to a patient, bills should be individually
identified and counted. A person who is blind or visually impaired usually identifies currency by folding it in different ways and-or by placing different denominations in separate locations in a wallet or purse. Identifying coins is usually not a problem because of their varying sizes and milled edges. Credit cards should be handed to patients after imprint, not simply laid on a counter or table. A piece of cardboard or a plastic or metal signature template can be used to indicate where a signature is required. Place the cardboard edge horizontally below a signature line or orient the opening of signature template where signature is required.

[4] Sighted guide technique and mobility aids. Staff should not touch or remove mobility canes (such as the long white cane) unless requested to do so and should not interfere with dog guides. Identify yourself and offer guide assistance if it appears to be needed. If assistance is accepted, offer your arm to the patient. The patient will lightly hold your arm directly above the elbow.
Don't pull or push the patient or hold his or her arm. Relax and walk at a comfortable, normal pace. Allow the patient to walk a
step or two behind you, and indicate changes in terrain, such as stairs, narrow spaces, and escalators, by hesitating briefly as you approach them and explaining what you are about to do. This standard form of sighted guide technique should be modified,
however, if the patient's other disabilities require him or her to be supported by the guide. When seating the patient, ask if you may show him or her the back of the chair. If the response is yes, simply place the patient's hand on the chair back. When it is time for you to leave, indicate that you are leaving his or her presence. If it is necessary to take an individual's cane, tell the
person you are removing it and where it can be retrieved.

[5] Verbalizing directions. Be specific. Be sure to use right and left as they apply to the person who is blind. What is on your
right is on the left of a person facing you. Indicate number of blocks to the bus stop and whether one proceeds right or left when exiting the hospital. Provide the name of the street corner at which the stop can be found. Simply saying, "The bus stop is about
six blocks down in that direction" is ineffective. Similarly, be specific about directions to rooms within your facility, e.g., "To
find the cardiac rehabilitation unit, go to the end of this corridor, turn left, and it is the fifth room on your right." In addition, the layout of a patient's room can be verbalized, or if the patient is not otherwise incapacitated, a walk-around orientation can be offered. Other solutions include the provision of tactile maps, large-print maps, or recorded materials as aids to wayfinding.

 [6] Using disability-sensitive language and etiquette. Using words such as blind, visually impaired, seeing, looking, and watching television is acceptable in conversation. Similarly, using descriptive language, including references to color, patterns, and the like is appropriate. When referring to patients with disabilities, refer to the person first, then the disability, e.g., refer to the patient in 439 who is blind rather than the blind man in 439. Talk directly to the person you are addressing, not through a companion. Speak in normal conversational tones. It is not necessary to raise your voice.

[7] Communicating with persons who are deaf-blind. Most persons who are deaf-blind communicate using finger spelling, printing letters in the palm, or tactile American Sign Language. The patient who is deaf-blind may also use braille or large print if he or she has some residual vision. Remember to ask how your patient prefers to receive information from you and how you can recognize that your message has been understood by your patient. Subject to the undue burden defense, the ADA requires the provision of interpreters only if the communication is particularly complicated. Interpreters should be present in situations to provide effective communication for lengthy or complex information, such as discussing a patient's medical history; obtaining informed consent; obtaining permission for treatment; discussing the diagnosis, course of treatment, or outcome; counseling; or discussing cost of treatment. If a tactile interpreter is required, you may be able to find one through the Registry of Interpreters for the Deaf listed in the Yellow Pages or through a local sign language or deaf service agency. For more routine communication, printing in the patient's palm may be all that is necessary. If this does not effectively communicate the
procedure to be performed and if an interpreter is unavailable, allow your deaf-blind patient to touch the equipment involved, such as a blood pressure cuff or empty syringe, by gently placing his or her hand on it. Never perform a procedure without some advance warning (see Note  [11]). In addition, staff should be aware of the universal sign for an emergency situation, i.e., drawing the letter X on the back of the person who is deaf-blind with the fingertips. Aids such as the Brailtalk tactile communicator can also facilitate communication. This is an inexpensive plastic device that contains braille and raised character alphabet and numerals. For many people who are deaf-blind, communication can be accomplished using this device by simply pointing the finger to the appropriate braille or raised letters or numerals. In addition, some persons who are deaf-blind may use combination braille and print "help cards" containing basic messages.

[8] Dog guides. The ADA requires admission of service animals to hospitals, offices of health care providers, and similar facilities unless a fundamental alteration would result or safe operation would be jeopardized. The presence of a "direct threat" to health or safety must be determined by competent personnel, based upon medical or other evidence. The exclusion of the animal cannot be based on stereotype or conjecture as to the health or safety threat involved. The dog guide should always remain under control by its owner. In addition, care and supervision of the animal is the responsibility of the patient or visitor. Staff should not pet, feed, or otherwise distract dog guides from their work. Although the ADA does not require you to provide a dog guide relief area, it would be helpful to your patients or visitors who use dog guides if you can provide some suggestions in this regard.

[9] Identifying visual acuity. With rotation of hospital staff, it is sometimes necessary to alert staff concerning a patient's visual
disability. This should be done in a dignified manner and in such a way as to communicate the patient's functional ability. A note in a chart such as "Patient is blind" does not communicate that the patient is actually visually impaired, reads printed materials with a monocular lens, has no difficulty in getting around the hospital room, but usually cannot visually recognize staff. Thus, the usual chart note that the patient is "blind" is really quite meaningless. A simple note that staff should inquire about the patient's visual disability, as circumstances require, is all that is usually necessary. If the patient's eye condition involves symptoms that
could be confused with other signs or symptoms indicative of trauma or disease, this information should be noted.

[10] TDDs for patients who are deaf-blind. Subject to the undue burden defense, a hospital that permits its patients to make
outgoing calls on "more than an incidental, convenience basis" must, upon request, provide a TDD (telecommunications device for the deaf) for the patient's use. Accordingly, a hospital may be required to provide a braille-output TDD to a patient who is
deaf-blind. Such equipment may be purchased, or perhaps rented or borrowed from the manufacturer or from a state or local service agency for blind or deaf persons. In addition, a personal alert system which convert sounds from sources such as a smoke alarm or telephone into vibrations which can be felt by a person who is deaf-blind is another example of an accommodation for such a patient. This equipment can be obtained from the sources just mentioned.

[11] Verbalizing or demonstrating procedures before they are performed. This is absolutely essential and will help to put your
patient at ease. Talk to your patient. Describe the procedure before you perform it and-or permit the patient to inspect the
equipment being used. "Mr. Jones, I'm Pete Walters, an EKG technician. Have you ever had this procedure done before? No? Well, I'll first be placing an EKG lead on your chest. Would you like to see what the instrument looks like?"

[12] Customizing treatment and discharge plans. It is important that treatment and discharge plans be tailored to meet the life-style of a patient who is blind, deaf-blind, or visually impaired. For example, a cane or dog guide user may not be able to use crutches effectively but could remain ambulatory if outfitted with a mechanical or walking cast instead of a rigid cast. Assuming that both casts are equally therapeutic, the more elaborate and expensive mechanical cast will afford a much greater degree of independence and manageability for your patient who is blind, deaf-blind, or visually impaired and thus is a much more appropriate treatment option. Similarly, discharge planners and other staff should be aware of the range of abilities of persons with vision loss and the availability of equipment and devices that can make self-care possible, e.g., talking thermometers, talking blood pressure and glucose monitoring equipment, and dosage measuring devices. Dieticians and other staff should also be aware of cooking and other independent living skills possessed by many blind persons and should be willing to alter meal plans to include low fat and low sodium microwave easy-to-prepare dishes if a patient does not have cooking skills. Today, blindness or visual impairment alone does not always require convalescence in a nursing home for patients who otherwise lead independent lives. For the newly blinded patient, whether vision loss is caused by accident, illness, or is incidental to the hospital admission, staff should consult with state or local blindness service delivery agencies to ensure immediate services and continuity of care after discharge.

[13] Identifying medication. While the patient is hospitalized, this is usually not a problem since all patients are not permitted to
self-medicate. Names of medications and their dosages can be recorded on cassette tape for the patient. In addition, advice can be given to the patient about labeling of prescription bottles or containers. Some methods of labeling include: the use of an
inexpensive device that produces self-adhesive Dymo-type labels for affixing to bottles or containers; use of different size bottles or containers with notes kept about the contents of each size package; use of rubber bands and paper flag-type labels that can be brailled or printed in large print using a wide point felt tip pen, or brailled and raised character pill sorters.

[14] Food service assistance. Such assistance could include reading and completing menus, identifying items on a patient's tray, or cutting meat on request. For buffet or cafeteria service, assistance may include identifying and-or serving food from the
buffet table or cafeteria line and assisting a visitor or patient to locate an available table in the dining area. For table service,
the waiter should explain arrangement of the tableware and announce the placement of food and beverage items as they are served. Assistance in feeding is not required by the ADA unless this service is provided to all patients when necessary, regardless of disability.

[15] Accessible signage and other ADAAG requirements. The ADA Accessibility Guidelines (ADAAG), which is available as an appendix to the Justice Department's Title III regulations, contains several provisions concerning accessible signage: braille, raised characters, contrast, serif, and character height. In addition, the ADAAG contains provision regarding braille and raised character elevator controls, audible direction and floor indicators for elevators, and floor designations on elevator hoistways. The ADAAG also contains provisions regarding protruding objects, stairs, and handrails. These ADAAG requirements generally must be incorporated into new construction and must be incorporated when facilities are being altered. Items such as raised character and braille elevator controls are usually required to be installed in existing facilities, because they involve little difficulty or expense and are generally considered to be readily achievable.

[16] These items are not reflected in the ADAAG but are listed here because awareness of the barrier that they represent to persons who are blind or visually impaired will aid architects and designers in the development of appropriate standards. For example, although inadequate lighting, glare and interference from masking sounds present significant barriers to access for many persons who are visually impaired, the ADAAG currently do not contain standards relative to ambient lighting, glare control, or white noise.

[17] Identifying community-based programs. The organizations listed in the resource section of this pamphlet can provide you with information concerning state and local service agencies for the blind, deaf-blind, or visually impaired or self-help consumer
advocacy groups. A national directory of services for persons who are blind, deaf-blind, or visually impaired is also available for purchase from the American Foundation for the Blind. To ensure continuity of care for the newly blinded child, parents should also be advised of their child's right to a free appropriate public education provided by the local school district.
 
 

Government Agencies

You can obtain further information, copies of the ADA regulations, and technical assistance manuals from the following government departments or agencies:

Title I (Employment)
Equal Employment Opportunity Commission
1801 L Street, N.W.
Washington, DC 20507
800-669-EEOC; 202-663-4399 (TDD)

Title II (State and Local Governments)
Title III (Public Accommodations)
Public Access Section
Civil Rights Division
U.S. Department of Justice
P.O. Box 66738
Washington, DC 20035-9998
202-514-0301; 202-514-0383 (TDD)

Title II/Title III (Transportation)
U. S. Department of Transportation
400 Seventh Street, S.W., #10424
Washington, DC 20590
202-366-9306; 202-755-7687 (TDD)

Advocacy Organizations

You can obtain further information about accommodations for people who are blind, deaf-blind, or visually impaired from the following organizations:

American Association of the Deaf-Blind
814 Thayer Avenue
Silver Spring, MD 20910
301-459-2121 (Voice); 301-588-6545 (TDD)

American Council of the Blind
1155 15th Street, N.W., Suite 720
Washington, DC 20005
202-467-5081 (Voice)

American Foundation for the Blind
Governmental Relations Department
1615 M Street, N.W., Suite 250
Washington, DC 20036
202-457-1487 (Voice/TDD)

Council of Citizens with Low Vision International
5707 Brockton Drive #302
Indianapolis, IN 46220
800-733-2258 (Voice); 317-254-1185 (Voice)

National Federation of the Blind
1800 Johnson Street
Baltimore, MD 21230
410-659-9314 (Voice)
 

The Americans with Disabilities Act Communications Accommodations Project is a joint program of the American Foundation for the Blind and the National Center for Law and Deafness.

Additional copies are available from the Governmental Relations
Department, American Foundation for the Blind, 1615 M Street, N.W.,
Suite 250, Washington, DC  20036.

This document provides general information to promote voluntary compliance with the Americans with Disabilities Act (ADA). It was prepared under a grant from the U.S. Department of Justice. While the Department's Public Access Section has reviewed its contents, any opinions or interpretations in this document are those of the American Foundation for the Blind and do not necessarily reflect the views of the Department of Justice. The ADA itself and the Department's ADA regulations should be consulted for further, more specific guidance.

American Foundation for the Blind.
 
 

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