WISCONSIN TALKING BOOK AND BRAILLE LIBRARY
813 West Wells Street
Milwaukee, WI 53233-1436
414-286-3045 (in Milwaukee)
800-242-8822 (in Wisconsin)

Certificate of Eligibility and Application for Library Services for Individuals

Braille books and magazines, books and magazines recorded on cassette tape or digital cartridge, and audio-described videotapes are loaned to individuals who are unable to read or use normal printed materials as a result of blindness, visual disability or physical limitations.

This CERTIFICATE OF ELIGIBILITY must be completed and signed by a competent authority OTHER than the applicant's immediate family. In cases of blindness, visual disability or physical limitations, "competent authority" is defined to include doctors of medicine and osteopathy, ophthalmologists, optometrists, registered nurses, therapists, professional staff of hospitals, institutions and public welfare agencies (such as social workers, case workers, counselors, rehabilitation teachers and superintendents). In the absence of any of these, certification may be made by a professional librarian or by any person whose competence under specific circumstances is acceptable to the National Library Service (NLS) for the Blind and Physically Handicapped, Library of Congress, Washington, DC. NLS administers the federal law under which the Wisconsin Regional Library for the Blind and Physically Handicapped operates.

In the case of reading disability from organic dysfunction, competent authority is defined as doctors of medicine or osteopathy ONLY, who may consult with colleagues in associated disciplines.

(Please print or type.)
NAME OF APPLICANT__________________________________________________________________
C/o_______________________________________________________________________________
Street Address_______________________________________________ Apt. No. __________
City_____________________________ County ___________________________Zip_____________
Telephone (_____)___________________ Date of Birth_________________________ Sex ________

The above-named individual is unable to read or use normal printed materials as a result of the following physical limitation (see below for definitions).
_____Visual handicap
_____Blindness
_____Deaf-blind
_____Physical handicap
_____Reading disability

In addition to any of the conditions above, does applicant also have a hearing impairment? If yes, indicate degree of hearing loss.
_____Moderate
_____Profound

Definitions of Physical Limitations

VISUAL HANDICAP: Lacks visual acuity to read standard printed materials without special aids or devices other than regular glasses.
BLINDNESS: Visual acuity of 20/200 or less in the better eye with correcting glasses or the widest diameter of visual field subtending an angular distance no greater than 20 degrees.
DEAF-BLIND: Severe auditory impairment in combination with legal blindness.
PHYSICAL HANDICAP: Unable to hold a book or turn pages as a result of physical limitations. Examples include: without arms or the use of arms; impaired or weakened muscle and nerve control; limitations resulting from strokes, cerebral palsy, multiple sclerosis, muscular dystrophy, polio, arthritis, or similar conditions.
READING DISABILITY: Organic dysfunction of sufficient severity to prevent reading printed materials in a normal manner. IF THIS DISABILITY IS CHECKED, A MEDICAL OR OSTEOPATHIC DOCTOR MUST SIGN.


TO BE COMPLETED BY CERTIFYING AUTHORITY
I certify that the Applicant named has requested library service and is unable to read or use standard printed material for the reason indicated above. (Please print or type.)
Authority Name________________________________________________ ___________________
Title and Occupation_________________________________________________________________
Street_____________________________________________________________________
City__________________________________ State________ Zip__________
Telephone_________________________________________________________________
Authority Signature__________________________________________________________________
Date_________________________________


In case we need to contact the Applicant but cannot, is there someone whom we can contact? (If the Applicant is a child, give parent's name.)
Alternate Contact's Name______________________________________________________________
Home Telephone (_____)_____________________
Work Telephone (_____)______________________

Should we send your books to an address other than your residence? NO_____ YES _____ If "yes," where should we send them?
C/o Name ________________________________________________________________
Street ___________________________________________________________________________
City________________________________________ State _______________ Zip ______________

NOTICE: All patron records pertaining to this service will remain confidential, but if you would like your name released to your local public library only in order to receive information, please initial here.______

BY LAW, PREFERENCE IN LENDING BOOKS AND EQUIPMENT IS GIVEN TO VETERANS. PLEASE CHECK HERE IF YOU HAVE BEEN HONORABLY DISCHARGED FROM THE ARMED FORCES OF THE UNITED STATES. _____

Have you ever used Talking Books before? NO _____ YES _____ Where?________________________

LANGUAGES: Will you borrow books in languages besides English? NO _____ YES _____
Which languages do you understand?_________________________________________________________

CHECK PREFERRED READING LEVEL:
K-3_____ 3-6_____ 6-9_____ Young Adult _____ Adult _____

WOULD YOU ACCEPT BOOKS WITH:
Strong Language? Yes_____ No_____
Explicit Descriptions of Sex? Yes_____ No_____
Violence? Yes_____ No_____

MATERIALS AVAILABLE (Please check materials wanted.)

_____*Standard Cassette Book Machine and books recorded on 4-track cassette tape.
_____*Digital Talking Book Player and books recorded on digital cartridges. (Ask the Library about downloading digital talking books.
_____Braille books.
(*It is necessary to borrow a machine from the library as both digital cartridges and cassette tapes have been recorded in formats not compatible with commercial digital players and cassette equipment.)

SPECIAL ATTACHMENTS (Please check only those items needed.)
_____Extension levers--assist the physically handicapped in manipulating the function keys of a cassette book machine.
_____*Amplifier/headphone system--SOLELY for the use of the severely hearing-impaired.
_____*Breath switch--SOLELY for the use of the severely physically-impaired.
_____*Remote control unit--SOLELY for the use of those confined to bed or with very limited mobility.
_____*Solar battery charger--SOLELY for the use of those living without electricity in the home.

(*NOT AVAILABLE DIRECTLY FROM THIS LIBRARY. These attachments are loaned from the Library of Congress. If you indicated a need for any of these attachments, the appropriate application forms will be sent to you.)

RETURN OF EQUIPMENT
Playback equipment and special attachments are supplied to eligible persons on extended loan. If this equipment is not being used in conjunction with recorded reading material provided by the Wisconsin Regional Library, it must be returned.

CIRCULATION OF MATERIALS (Please check ONE of the following.)

_____AUTOMATIC SELECTION: Send books on a continuing, rotating basis, by subject indicated below. As each book is returned to the Library, it will be replaced with a new book.
OR
_____BY REQUEST ONLY: Send only the specific titles I request. Do not select books for me.

READING INTERESTS (Please check the subjects you want books chosen from. Do NOT check off the subjects if you wish to choose your own books.)

FICTION

___Adventure (010)

___Holidays (253,256,261)

___Science Fiction (180,394)

___Animal (011)

___Horror (162,399)

___Sea Stories (015)

___Best Sellers (391)

___Humor (277)

___Short Stories (258)

___Classics (060)

___Modern Novels (246)

___Sports (249)

___Family (243)

___Mysteries (140,393)

___Spy (144)

___Family Sagas (273)

___Mysteries, Deductive (141)

___Suspense (147,397)

___Fantasy (181)

___Mysteries, Tough (142)

___War (200)

___Gothics (080)

___Nature (014)

___Westerns (220)

___Historical (100)

___Radio Shows (527)

___Wisconsin (267)

___Historical-US (106,107)

___Romances (120,396)

___World War I (203)

.

.

___World War II (204)

 

 

 

NONFICTION

___Adventure (400)

___Handicaps (700)

___Poetry (730)

___Animal (404,803)

___History (560,570)

___Politics (755,501

___Archeology (811)

___History-US (566,567,568,571)

___Psychology (745)

___Best Sellers (392)

___Hobbies (585)

___Religion-Catholic (760)

___Biography (440,450,398)

___Humor (600)

___Religion-Protestant (780)

___Black (420)

___Inspiration (743)

___Religion-Other (490,917)

___Business (480)

___Science (800,810,820)

___Computers (930)

___Jewish (620)

___Sociology (503,746)

___Cooking (583)

___Literature and Criticism (916)

___Sports (840)

___Crime (901)

___Marriage (748)

___Theatre (523)

___Current Events (500)

___Medicine (540)

___Travel (860)

___Economics (903)

___Movie/TV (275,522,526,449)

___Travel-US (864)

___Essays (912)

___Music, About (640)

___War (880)

___Fine Arts (520)

___Occult (660)

___Wisconsin (571)

___Folklore (902)

___Philosophy (680)

___World War I (883)

___Games (913)

___Plays (720)

___World War II (884)

___Gardening (584)

.

.

___Geography (530)

Other subjects of interest to you that we did not list:
_________________________________________________________________________________________
_________________________________________________________________________________________

THE FOLLOWING BI-MONTHLY PUBLICATIONS LIST NEW BOOKS (Please indicate the one you want by checking the desired format.)

TALKING BOOK TOPICS (Check one) in: Large Print_____ Cassette_____

BRAILLE BOOK REVIEW (Check one) in: Large Print_____ Braille_____

MAGAZINES: The Wisconsin Talking Book and Braille Library has a list of magazines which are available at no charge to registered patrons. The magazines are in Braille or recorded format. If you would like a copy of MAGAZINES IN SPECIAL MEDIA, check here_____.

AUDIO-DESCRIBED VIDEOCASSETTES AND DVDS: You may request a list of audio-described videos, which can be played on a standard commercial VHS player or DVD player. You may borrow described videos for one week only. If you would like a copy of the VIDEO CATALOG, check here_____.


PLEASE NOTE: Upon receipt, this application will be processed as soon as possible. However, please allow approximately one month's time before you receive the special equipment, accessories and books. Within that time period, you will receive a packet containing the "Handbook for Borrowers," catalogs and other important information with specific details of how to order and receive the items you wish to borrow. Questions? Phone us at 1-800-242-8822 or, in Milwaukee, 286-3045.

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