Massachusetts Commission for the Blind (MCB) / American Printing House for the Blind (APH) Federal Quota Program

To register a person to receive free materials from the American Printing House for the Blind, Federal Quota Program, please begin the process by filling out the attached form.

Eligibility requirements for the Massachusetts Commission for the Blind (MCB) APH Federal Quota Program: 
•	Be registered with MCB, and over the age of 18 and/or out of High School.
•	Have had an eye exam within the past 3 years and can provide the name, address, and phone number of the eye care provider (ophthalmologist or optometrist).  An APH Medical Eye Report form will be sent to the eye care provider to verify Legal Blindness.
•	Have received a minimum of 20 hours of documented instruction per week for 12 weeks in the preceding calendar year from a rehabilitation or educational program; and be registered in the current calendar year to receive the same (a minimum of 20 hours of instruction per week for twelve weeks).  
•	Regarding the minimum of 20 hours of instruction per week for 12 weeks: 
o	The 12 weeks do not need to be consecutive: Although social and leisure programs do not qualify as instruction, practice to develop skills can be used toward instructional hours. 
o	Acceptable Documented Instruction include:  
Day Habilitation Support Plan (DHSP)
Individualized Service Plan (ISP)
o	Rehabilitative Programs include: 
Adult Day Health Program
Community Based Day Program
Mobile Day Services (for adults who do not attend a rehabilitative program, but who have a service plan with instructional and rehabilitation goals). 

If you work with an individual who meets the above eligibility, please fill out and send the attached registration form to:
			Lisa DiBonaventura, MA, COMS
		  	Statewide Director for Vision & Vision Loss Services / DDS	
	Lisa.DiBonaventura@state.ma.us       Fax: (508) 384-5612

Please feel free to call with any questions (508) 384-5539 
Pre-registration for Massachusetts Commission for the Blind
American Printing House for the Blind Federal Quota Account

1. Please fill out ALL sections of this form completely.  Thank you!
2. Please have the individual’s guardian sign the APH Consent Form and send this along as well.

Today’s Date:        

Name:      
Home Address:      
Name of Contact at Home:      
Email Address of Contact at Home:      

MCB reg# (If known) or SS#:       DOB:      

Day Hab or Pre Voc Program Address & Phone:       
Name of Contact at Day Hab or Pre Voc Program:      
Email Address of Contact at Day Hab or Pre Voc Program:      

Primary Reading Medium: CHECK ONE: Visual (V); Braille (B);
 Auditory (A); Prereaders (P); Nonreaders (N)

Secondary Reading Medium: CHECK if different choice from above: 
Visual (V); Braille (B); Auditory (A); Not Applicable (NA)

Third Reading Medium: If applicable and different from 1st and 2nd choice:  
Visual (V); Braille (B); Auditory (A); Not Applicable (NA)

Primary Language Please Check One:  
  English           Spanish             Other Please State:      

Name, Address & Phone of Eye Doctor:      

DDS Service Coordinator or MCB Case Manager & Phone:      
DDS Region:          
DDS Area Office:       
Name of Person filling out this form:      
Phone:      
Email address:      

Return both this form and the Consent Form by Fax or E-Mail to: 	

			Lisa DiBonaventura, MA, COMS
		  	Statewide Director for Vision & Vision Loss Services / DDS

			Lisa.DiBonaventura@state.ma.us
			Office: (508) 384-5539		Fax: (508) 384-5612

Dear Individual/Parent/Guardian,

The purpose of this letter is to inform you that Massachusetts Commission for the Blind (MCB) and Department of Developmental Services is in the process of completing the Annual Federal Quota Registration of Blind Students of all ages through the American Printing House (APH) Federal Quota Program. This federally funded program provides textbooks, educational aids, and other learning materials for qualifying students of all ages with visual impairment and blindness.  

In order to be included in the Federal Quota program, eligible adult students must be registered in an annual census, requiring the exchange of specific personally identifiable student information (PII). This information is only collected to meet the reporting obligations to the U.S. Department of Education, Office of Special Education Programs, and other entities as required by law. The Family Educational Rights and Privacy Act (FERPA) requires your consent to release personally identifiable information.

The name(s) of you or your dependents will be registered, along with other pertinent information including birthdate, hometown, program town, primary reading medium, and indication of visual function. All PII collected for this registration is confidential and will be protected from unauthorized access or use. Your dependent’s PII will not be shared with any other entities or for any other purpose, unless permitted by state or federal law.  

The Federal Quota Census Registration is completed under the supervision of the Ex Officio Trustee (EOT) designated to oversee his or her respective APH accounts. It is the responsibility of the EOT to submit accurate information to APH in a secure manner; therefore, the EOT determines the manner in which information is collected and subsequently sent to APH in Louisville, KY. If you have questions or concerns regarding the Annual Federal Quota Registration Process, please contact John Oliveira, EOT, Deputy Commissioner or Adrienne Callaghan White, EOT Assistant, at MCB.

Your written consent is required in order to provide this information to APH. Consent to include your/your dependent’s name in the Federal Quota Census allows the Massachusetts Commission for the Blind and Department of Developmental Services to obtain products and materials from the APH on your behalf. You may choose not to provide your consent; however, doing so will mean that fewer Quota funds will be provided to Massachusetts.
   
Please return completed form via email, fax, or mail: Sandra M. Faulkner, Admin. Assistant, Statewide Vision & Vision Loss Services, DDS, Office: 508-384-5679, Fax: 508-384-6771
Sandra.M.Faulkner@MassMail.State.MA.US Sandra Faulkner WDC, P.O. Box 144, Wrentham, MA 02093.
Thank you,

John Oliveira, Deputy Commissioner, MCB

Massachusetts Commission for the Blind
Consent to Release Adult Student Information

In order to register and receive orders from the American Printing House for the Blind (APH*), I hereby authorize the Massachusetts Commission for the Blind to share my or my dependent’s personally identifiable information as follows: Last Name, First Name, Middle Name, Date of Birth hometown, program town, Visual Function, Primary and Secondary Reading Medium, and cross reference of siblings also registered (to prevent duplication of registration).  

I, ______________________________________________ (print name), certify that I am the individual/parent/guardian (please circle) of ______________________ (adult student’s full name), whose date of birth is _________________________ (adult student’s complete date of birth), and that s/he is a dependent according to Section 152 of the Internal Revenue Code if s/he is over eighteen years of age.  I understand that this release will remain in effect unless I revoke it in writing.  I further understand that I can revoke this release at any time by sending an email to John.Oliveira@state.ma.us.

_____________________________________		________________
Individual/Parent/Guardian Signature 				Date
*APH is a nonprofit organization for the blind.  According to the Federal “Act to Promote the Education of the Blind”, all students who meet the definition of blindness can receive specialized textbooks and accessible materials through the APH Federal Quota Program.  

Please return completed form via email, fax, or mail: Sandra M. Faulkner, Admin. Assistant, Statewide Vision & Vision Loss Services, DDS, Office: 508-384-5679, Fax: 508-384-6771. Sandra.M.Faulkner@MassMail.State.MA.US  
Sandra Faulkner WDC, P.O. Box 144, Wrentham, MA 02093.