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KCDHH General Request Form

Please complete this form to request general information from KCDHH.
The yellow '*' denotes required entries and numbers in parentheses denote character limits.

*First Name (20)

*Last Name (20)

*Address 1 (30)

Address 2 (30)

*City (25)

*State

*Zip (10)

*First Phone Number (15):

Voice TDD V/TDD Video Phone

Second Phone Number (15):

Voice TDD V/TDD Video Phone

Third Phone Number (15):

Voice TDD V/TDD Video Phone

*E-mail address (40):

*Date of birth:
Note: Used for identification purposes only.

*I am:

*I am or I am representing a(n):

Name of Organization/Agency (if applicable)(20):

Your Title (if applicable)(15):

I would like to have:

TAP Program Application
Where can I buy Assistive Equipment?
How to Cope with Hearing Loss?
Hard of Hearing Info Packet
My Child has a Hearing Loss Info Packet
Where can I take Sign Language Classes?
How do I become an interpreter?
CEUs in Professional Development on Interpreting

Or

Please briefly describe your request or comment (500):





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KCDHH Inter-Agency Access Center Request Form
*FOR STATE AGENCY USE ONLY*
Please complete this form to request an interpreter, captioner, or Video Remote Interpreter referral from KCDHH. *For more information about Video Remote Interpreting (VRI), please see below.* The yellow '*' denotes required entries and numbers in parentheses denote character limits.
*Agency (30)
*Requestor's First Name (20)
*Requestor's Last Name (20)
*Address 1 (30)
Address 2 (30)
*City (25)
*State	*Zip (10)
*Phone Number (15):

*Requestor's date of birth: Note: Used for identification purposes only.

*Service Needed

*Date of Assignment

*Beginning Time

*Ending Time

*Consumer's First Name (20):
*Consumer's Last Name (20):

*Type of situation (50):

Location of assignment:
*Building Name (20)
*Address 1 (30)
Address 2 (30)
*City (25)
*State	*Zip (10)


*Billing approved: Yes No Note: This form will not submit without billing information.

Complete billing information:
*First Name (20):
*Last Name (20):
*Address 1 (30)
Address 2 (30)
*City (25):
*State:	*Zip (10)

Video Remote Interpreting Like most states, Kentucky faces a shortage of licensed interpreters throughout the Commonwealth, particularly in rural areas. Facing the crisis head on, KCDHH offers Video Remote Interpreting as a communication option allowing more flexibility for the deaf and hard of hearing consumer seeking state services. How it works Video Remote Interpreting (VRI) uses video–conferencing equipment to provide sign language interpreting services. Video–conferencing equipment is set up in the room where the deaf consumer is located and another will be set up where the interpreter is located, which could be in another city. This interpreter will use a head set to hear what the hearing person is saying and then will interpret the message through the use of a monitor and camera to the deaf consumer and then interpret from the deaf consumer to the hearing person. In this way, the deaf and hearing person can talk back and forth, just as if the interpreter was in the same room.

VRI Request
Like most states, Kentucky faces a shortage of licensed interpreters throughout the Commonwealth, particularly in rural areas. Facing the crisis head on, KCDHH introduced Videoconferencing as a communication option allowing more flexibility for the deaf and hard of hearing consumer seeking state services.
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Number of Sites Involved Number of Individuals involved Location of Site #1 Location of Site #2 Location of Site #3 Please indicate if you have a preferred interpreter or captioner





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KCDHH TAP Request Form
Please complete this form to request a TAP application from KCDHH. The yellow '*' denotes required entries and numbers in parentheses denote character limits.
Complete this form to receive a Specialized Telecommunications Equipment application from the Telecommunications Access Program (TAP) of KY.
*First Name (20):
*Last Name (20):
*Address 1 (30)
Address 2 (30)
*City (25):
*State:	*Zip (10):


*Date of birth: Note: Used for identification purposes only.

*First Phone Number (15): Voice TDD V/TDD Video Phone

Second Phone Number (15): Voice TDD V/TDD Video Phone

Third Phone Number (15): Voice TDD V/TDD Video Phone

*E-mail Address (40):
*I am:
*I am or I am representing a(n):


Name of Organization/Agency (if applicable) (20):
Your Title (if applicable) (15):





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KCDHH DeaFestival Information Request Form
Please complete this form to request information regarding the DeaFestival from KCDHH. The yellow '*' denotes required entries and numbers in parentheses denote character limits.
*First Name (20):
*Last Name (20):
*Address 1 (30)
Address 2 (30)
*City (25)
*State				*Zip (10)

*Date of birth: Note: Used for identification purposes only.

*First Phone Number (15): Voice TDD V/TDD Video Phone

Second Phone Number (15): Voice TDD V/TDD Video Phone

Third Phone Number (15): Voice TDD V/TDD Video Phone

*Email address (40):

Name of Organization/Agency (if applicable)(20):
Your Title (if applicable) (15):

*Are you:

*I am (or representing) a:

I would like to request: DeaFestival Information A DeaFestival Poster

Note: Not all posters are available
1996	1997	1998	2000	2002	2004	2006	2008

I would like to request a:
Or Please briefly describe your request or comment (500):





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KCDHH Visor Card Request Form

Please complete this form to request a Visor Card from KCDHH.
The yellow '*' denotes required entries and numbers in parentheses denote character limits.

Visor Communication Card Program

The Visor Communication Card Program is a combined effort of the Kentucky Commission on the Deaf and Hard of Hearing (KCDHH) and the Kentucky State Police. The laminated cards, which feature simple traffic signs on the front, with specialized instructions for law enforcement on the back, are being distributed to deaf, oral deaf and hard of hearing consumers throughout Kentucky.

The cards are thin and lightweight, designed to fit under the sun visor for quick communication access in traffic stops or other interaction with law enforcement. In addition to consumers, state and local law enforcement throughout Kentucky are being trained to spot the cards and understand their significance.

To request a visor card please fill out the following request form and please remember to specify if you are hard of hearing, deaf or oral deaf. Visor cards are limited to one per person and residents of Kentucky only are eligible.

To print off a paper request to fill out and mail, please click here.

*First Name (20)

*Last Name (20)

*Address 1 (30)

Address 2 (30)

*City (25)

*State

*Zip (10)

*Date of birth:
Note: Used for identification purposes only.

*First Phone Number (15):

Voice TDD V/TDD Video Phone

Second Phone Number (15):

Voice TDD V/TDD Video Phone

Third Phone Number (15):

Voice TDD V/TDD Video Phone

*E-mail Address (40):

*Are you (please select one):

*I am or I am representing a(n):

*A Police Visor Card
(please select which card you need)

	Deaf
	Oral Deaf
	Hard of Hearing

The following is additional information offered by KCDHH that is available upon request:

Information on Telecommunications Access Program (TAP) equipment distribution
TAP Program Application
Where can I buy Assistive Equipment?
How to Cope with Hearing Loss?
Hard of Hearing Info Packet
My Child has a Hearing Loss Info Packet
Where can I take Sign Language Classes?
How do I become an interpreter?
CEUs on Professional Development in Interpreting

Or

Please briefly describe your request or comment,
at most 500 characters:





Close Form

Kentucky Commission on the Deaf and Hard of Hearing
632 Versailles Rd.
Frankfort, KY 40601
(502)573-2604

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What type of request do you wish to make?

KCDHH General Request Form

KCDHH Inter-Agency Access Center Request Form

Location of assignment:

Complete billing information:

Video Remote Interpreting

How it works

KCDHH TAP Request Form

KCDHH DeaFestival Information Request Form

Note: Not all posters are available

KCDHH Visor Card Request Form

Visor Communication Card Program