2017-2018 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 UNLESS OTHERWISE ARRANGED.

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 atohio@osu.edu.

A copy of this request will be emailed upon submission.

Email address *
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.
Name of Device(s) *
Please specify the name of the device. Do NOT use the inventory number.
Your answer
BORROWER'S INFORMATION
The "Borrower" is the person requesting the device and signing the form.
Name *
Your answer
Name of Agency / Organization / School *
If not applicable, type in NONE
Your answer
PREFERRED SHIPPING ADDRESS
Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Phone Number During Business Hours *
Please use hyphenated format (eg. 123-456-7890)
Your answer
Alternate Phone Number
Your answer
Person signing this form is
Please select main area in which the device will be used *
Required
Please select the primary purpose of the device loan *
Required
NAME OF PERSON WHO WILL BE USING THE DEVICE
User's Name
If different from the person borrowing the device
Your answer
If a Minor, Name of Parent or Guardian
Your answer
Street Address
Your answer
City / State / Zip Code
Your answer
Name of Support Person
Someone who is able to train / assist in use of the device
Your answer
Title/Relationship of Support Person
Your answer
Support Person's Phone Number
Your answer
FEES
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
action.

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: Type your name in the box below. 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.
Borrower's Signature *
Your answer
Date *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
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