Form 3907 "Application for Specialized Telecommunications Assistance Program (Stap) Speech Generating Devices" - Texas

What Is Form 3907?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3907 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 3907 "Application for Specialized Telecommunications Assistance Program (Stap) Speech Generating Devices" - Texas

131 times
Rate (4.6 / 5) 9 votes
Form 3907
September 2020-E
Office of Deaf and Hard of Hearing Services (DHHS)
Application for Specialized Telecommunications Assistance Program (STAP) Speech Generating Devices
Step 1—Provide Applicant Information (the person using the equipment)
Applicant’s full name
Address Field
City
State
ZIP Code
Area Code and Telephone No.
Area Code and Telephone No.
TX driver's license number or TX ID number
Email Address
Date of Birth
Mailing address (if different from above):
Name
If the mailing address is not the applicant’s, specify the person’s relationship to the applicant
Address Field
City
State
ZIP Code
Parent's or legal guardian's name
Signature. This application must have an original signature—not a photocopy, facsimile, or stamped signature. If you are under
18, your parent or guardian must sign the application.
The following statement must be signed before the application can be processed.
I attest to the following:
• The applicant is a Texas resident.
• Due to a disability, the applicant requires a specialized telecommunications device to access the telephone network.
• The device selected will enable the applicant to access the telephone network.
• I understand that STAP may request additional documentation as needed to confirm or supplement any information
provided on the application, including physician’s statements or medical records.
• I understand that I have one year from the date the application is processed to provide any required additional information to
receive a voucher before I must complete another application to apply for a voucher.
• I consent to the applicant speaking to a STAP representative after receiving the specialized telecommunications device to
verify that the applicant can access the telephone network with the device received.
Applicant’s, parent’s, or legal guardian’s signature (must be original,
Date
not a photocopy, facsimile, or digital)
Printed Name
Relationship to applicant (applicant, parent, or legal guardian)
Mail to: STAP, P.O. Box 12904, Austin, TX 78711
This application form is valid until August 31, 2021
hhs.texas.gov/services/disability/deaf-hard-hearing
Form 3907
September 2020-E
Office of Deaf and Hard of Hearing Services (DHHS)
Application for Specialized Telecommunications Assistance Program (STAP) Speech Generating Devices
Step 1—Provide Applicant Information (the person using the equipment)
Applicant’s full name
Address Field
City
State
ZIP Code
Area Code and Telephone No.
Area Code and Telephone No.
TX driver's license number or TX ID number
Email Address
Date of Birth
Mailing address (if different from above):
Name
If the mailing address is not the applicant’s, specify the person’s relationship to the applicant
Address Field
City
State
ZIP Code
Parent's or legal guardian's name
Signature. This application must have an original signature—not a photocopy, facsimile, or stamped signature. If you are under
18, your parent or guardian must sign the application.
The following statement must be signed before the application can be processed.
I attest to the following:
• The applicant is a Texas resident.
• Due to a disability, the applicant requires a specialized telecommunications device to access the telephone network.
• The device selected will enable the applicant to access the telephone network.
• I understand that STAP may request additional documentation as needed to confirm or supplement any information
provided on the application, including physician’s statements or medical records.
• I understand that I have one year from the date the application is processed to provide any required additional information to
receive a voucher before I must complete another application to apply for a voucher.
• I consent to the applicant speaking to a STAP representative after receiving the specialized telecommunications device to
verify that the applicant can access the telephone network with the device received.
Applicant’s, parent’s, or legal guardian’s signature (must be original,
Date
not a photocopy, facsimile, or digital)
Printed Name
Relationship to applicant (applicant, parent, or legal guardian)
Mail to: STAP, P.O. Box 12904, Austin, TX 78711
This application form is valid until August 31, 2021
hhs.texas.gov/services/disability/deaf-hard-hearing
Form 3907
Page 2 / 09-2020-E
Step 2—Provide Proof of Residency
Include a copy of one of the following as proof of your Texas residency. Document must be current and dated within three months
of the date the application is received.
• Texas driver’s license
• vehicle registration card
• Voter registration card
• ID card with address
• Utility bill (showing address)
• Letter on the official letterhead of a residential facility signed by the facility
director or supervisor
Note: Proof of residency must name the applicant or the parent, or the legal guardian signing the application and show the
home address as it appears on the application.
Step 3—Device Options
You must meet the established disability requirements for the device requested.
Note: These disability requirements are defined in the form instructions.
SI = Speech impaired
CI = Cognitively impaired
LMI = Lower mobility impaired
UMI = Upper mobility impaired
Telecommunication Device or Software
Disability Requirements
SGD Level 1
(SI and CI) or (SI and UMI)
A hand-held device that generates digitized or synthesized speech using pictures.
SGD Level 2
A device that generates digitized or synthesized speech using pictures that may allow for
(SI and CI) or (SI and UMI)
switch access.
SGD Level 3
A device that generates digitized or synthesized speech using pictures that allow for eye
SI and UMI
control access.
SGD Switch
SI and UMI
A device that connects to an SGD to allow the user to review and make selections.
SGD Head Pointing or Movement Control Device
A device that connects to an SGD to allow access to an SGD using head or other body
SI and UMI
movements.
SGD Eye Control Access
SI and UMI
A device that connects to an SGD to allow access to an SGD using eye movements.
SGD Mount
SI and UMI
A device used to secure an SGD.
SGD Switch Mount
SI and UMI
A device used to secure an SGD switch.
SGD Moisture Guard
(SI and CI) or (SI and UMI)
A protective moisture barrier for an SGD device.
SGD Key Guard
(SI and UMI)
A protective overlay that helps to prevent inadvertent key activation.
Infrared Telephone
(SI and CI) or (SI and UMI)
A phone that can be operated by infrared transmitted signals.
Anti-Stuttering Device
Provides the user with Delayed Audio Feedback (DAF) and Frequency Shifted Audio
SI and UMI
Feedback (FAF). If an applicant is not certified as having an UMI, a voucher may be issued
at a lesser value.
Speakerphone
SI or UMI or CI
A phone with a speaker built into the base.
Form 3907
Page 3 / 09-2020-E
Step 4—Provide a Professional Certification of Your Disability
A licensed speech-language pathologist must complete this section unless only an anti-stuttering device is requested. A Texas
Workforce Commission VR counselor may complete this form for an anti-stuttering device. Additional documents to supplement
the pathologist’s response may be attached. Print clearly. Illegible information may be returned for clarification.
Applicant’s name (the person using the equipment)
Application number (for DHHS use only)
1a. Specify manufacturer and product name of device requested.
1b. Specify accessories requested, if any:
2. Describe how the equipment requested was selected. Include the names of all other devices that were tested during the
evaluation and explain why they are not being requested.
3. Is the applicant reapplying for a voucher because of a change of disability? ..........................
Yes
No
If yes, Form 3926, Change of Disability, must be completed. Contact
dhhs.stap@hhsc.state.tx.us
for this form or print it from
the DHHS website at
hhs.texas.gov/services/disability/deaf-hard-hearing
(under Telephone Access).
4. Describe what the applicant can do with the requested equipment in relation to accessing the telephone network.
Information provided must demonstrate that the applicant is able to use the device and that the applicant is able to
access the telephone networks using the device.
5. With use of the requested device, describe the applicant’s ability to:
a) Press an icon or combine icons to compose a message:
b) Compose a message through typing:
Form 3907
Page 4 / 09-2020-E
6. Provide a complete description of all limitations that interfere with the applicant’s ability to use a standard telephone.
a) cognitive status:
b) speech impairment status:
c) upper mobility status:
d) hearing status:
e) vision status:
Certification
As the certifier, I attest to the following:
• I am eligible to certify under the provisions of STAP.
• I have personally met with the applicant and have assessed the applicant’s disability to determine that he or she is eligible,
in accordance with the STAP eligibility criteria.
• I have determined that the applicant will be able to benefit from the specialized telecommunications device recommended
above to access the telephone network and that the applicant’s age or disability does not prevent him or her from using the
selected specialized telecommunications device to gain access to the telephone network.
• I understand that STAP may request additional documentation from me, the applicant, or other sources to confirm or
supplement any information provided on the application, including physician’s statements, medical records, or a copy of my
license or certificate.
• I understand that if I have violated or if I am suspected of violating any HHS policy or laws related to the STAP, including
certifying applicants who cannot access the telephone networks with the device requested, that I may no longer be
authorized to certify applications, and that if I have committed or am suspected of committing such violations, I may be
referred to my licensing agency.
• All information I have provided on this application is valid and accurate to the best of my knowledge.
Printed name of certifier
Speech language pathologist’s license number
Name of business
Address
City
State
ZIP Code
Telephone
Fax
Email
Certifier's signature (must be original, not a photocopy, facsimile, or stamp):
Date:
Page of 4