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2019-2020 Assistive Technology of Ohio Device Request and Agreement Form
This service is restricted to residents of Ohio.
Thank you for submitting your request to Assisitve Technology of Ohio's (ATOhio) short-term device trial program. Please allow 1-3 business days for your request to be reviewed by an ATOhio staff member. Should the equipment you requested not be available for trial, you will be added to the wait list to receive the equipment.
BORROWING PERIODS ARE 30-DAYS.
PLEASE NOTE: A SIGNATURE IS REQUIRED FOR DELIVERY. To avoid delays in delivery, make sure someone is available at the shipping address who can sign for delivery of your requested device.
Questions? Contact Assistive Technology of Ohio at 800-784-3425 or
A copy of this request will be emailed upon submission.
Device (s) Requested
Only 3 devices may be borrowed at one time, unless you make prior arrangement with Assistive Technology of Ohio. However, due to the demand for AAC (speech generation devices) only 1 AAC (speech generation device) may be requested at one time.
Device you wish to borrow
Please specify the name of the device. Do NOT use the inventory number.
The "Borrower" is the person requesting the device and signing the form.
Name of Agency / Organization / School (
If not applicable, type in NONE
PREFERRED SHIPPING ADDRESS
Is this a business or residential address?
Phone Number During Business Hours
Please use hyphenated format (eg. 123-456-7890)
Alternate Phone Number
Person signing this form is
An Individual with a Disability
A Family Member or Guardian
A Representative of Education
A Representative of Rehab / Healthcare
A Community Living Representative
Please select main area in which the device will be used
Please select the primary purpose of the device loan
NAME OF PERSON WHO WILL BE USING THE DEVICE
If different from the person borrowing the device
If a Minor, Name of Parent or Guardian
City / State / Zip Code
Name of Support Person
Someone who is able to train / assist in use of the device
Title/Relationship of Support Person
Support Person's Phone Number
At this time there are no rental fees to borrow Assistive Technology of Ohio's assistive technology devices. However, late fees may be charged for any equipment not returned by the due date. Late fees may be assessed at a rate of up to $25 per week, depending upon the device. Failure to return devices by the due date will subject you to all applicable late fees. Failure to return devices at all will subject you to appropriate legal action.
I understand that I may be subject to late fees or legal action if I fail to return devices by the due date.
RESPONSIBILITY AND LIABILITY
I understand that the device I am borrowing is the sole property of The Ohio State University. I do NOT have permission to transfer the device, other than as specified in the request form, to someone else. I do NOT have permission to keep this device, or to sell, donate or otherwise dispose of the borrowed device. I understand and agree that, as the Responsible Signing Party, it is my responsibility to ensure the timely return of devices to Assistive Technology of Ohio. I understand that failure to return borrowed items could be deemed as property theft, and that I will be subject to appropriate legal
i understand that the borrowing period is for 30-days unless otherwise arranged.
I understand and agree that I am responsible for proper handling and use of each borrowed device.
I am responsible for returning all components to Assistive Technology of Ohio’s Assistive Technology Lending Library in a timely manner and in accordance with shipping instructions. If I find that any components listed on the inventory sheet are missing when I open the shipping case, I must call the Assistive Technology Lending Library at 800-784-3425 or 614-292-2390 immediately so I will not be held financially liable for the missing components.
In the case of loss of a device or components, I may be held financially liable. In the event of loss, I will contact Assistive Technology of Ohio at 800-784-3425 or 614-292-2390 immediately.
In the case of theft, I will not be held responsible, as long as I immediately report the incident to the police and provide a copy of the police report to Assistive Technology of Ohio.
If an equipment breakage or malfunction occurs, I must immediately notify the Assistive Technology Lending Library Manager at Assistive Technology of Ohio (800-784-3425 or 614-292-2390). I will not be held responsible for equipment breakage or malfunction that occurs during normal use as long as I report it promptly.
I understand it is illegal to copy or distribute any software loaned through Assistive Technology of Ohio’s Assistive Technology Lending Library. Upon completion of the loan period, if I have loaded borrowed software on my computer, I will remove it.
Failure to comply with these responsibilities will result in loss of future access to Assistive Technology of Ohio’s Assistive Technology Device Library, in addition to applicable financial and/or legal liability.
I have read the Responsibiity and Liability Terms and Agree abide by them
RELEASE OF LIABILITY
I agree to indemnify and hold harmless the Assistive Technology of Ohio, The Ohio State University, The Ohio State University Research Foundation, and the State of Ohio, and any and all employees, agents or representatives of same, from damages to property or injuries (including death) to myself, and/or any other person, and any other losses, damages, expenses, claims, demands, suits, and actions by any party against Assistive Technology of Ohio, The Ohio State University, The Ohio State University Research Foundation, and the State of Ohio, and any and all employees, agents or representatives of same, in connection with loan(s) from Assistive Technology of Ohio’s Technology Loan Library.
I have read, understand and accept the Release of Liabilty
Applicant Signature or Authorized Representative
Electronic Signature Agreement: By selecting the "Submit" button you are signing this application electronically and agree that your electronic signature is the legal equivalent of your manual signature. By selecting "Submit" you accept the terms (above) of this application.
A copy of your responses will be emailed to the address you provided.
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