Name
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First Name
Last Name
Phone
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Organization Primary Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Organization Website
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Organization Phone
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(###)
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Does your organization serve multiple regions and/or states?
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If yes, please list the regions and/or states where you provide supports
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Total Number of People Supported (by the whole organization/in all programs)
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Total Number of Employees (within the whole organization/in all programs)
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Executive Director/President/CEO Name
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Primary Contact Name and Title
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Primary Contact Email
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Primary Contact Phone
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(###)
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How does your organization ensure the fundamentals of a person-centered approach are embedded in the organization?
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Self-Advocate Identification:
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Our organization engages/will engage in the following identification practices to determine who may benefit from technology as a natural support (select the most applicable responses):
Self-Advocate Assessment:
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Our organization engages/will engage in the following assessment practices to determine who may benefit from technology as a natural support (select the most applicable responses):
Self-Advocate Support Planning:
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Our organization engages/will engage in the following support planning practices (select the most applicable responses):
Reporting:
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Our organization engages/will engage in the following reporting practices (select the most applicable responses):
How did you learn about the Tech First Accreditation program?
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State agency
Website
Written materials
E-news or social media
Another service provider
Colleague
Conference
Webinar
Technology Vendor
Other
non-medical residential with in home direct care support staff available 24/7
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non-medical residential with in home direct care support staff LESS THAN 24/7
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non-medical residential with REMOTE direct support staff
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community supported or independent living (living by self, with roommates, or with family)
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personal care assistance services
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respite care services
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supported employment
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day services with people at a community location
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transportation
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supported independent living for people with mental health conditions
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supported employment for people with mental health conditions
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Organization Technology Planning
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Our organization has (select the most applicable responses):
We have an internal team of people ready to lead the Tech First transformation.
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Describe your organization's commitment to Tech First transformation
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In a few paragraphs, define your organization's commitment to the Technology First transformation process:
-Provide 3-5 specific examples of practices, policies, and/or programming that support your statement.
-Specifically, include education and training, communication with stakeholders, and engagement of stakeholders in the transformation process.
What sources of funding will be accessed to purchase enabling technology products and services?
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Will your organization receive a value-based incentive from your funding source if you become accredited as a Technology First organization?
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Does your organization use an electronic source of data collection for record keeping?
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Please list any technology vendors you have purchased from or connected with:
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(i.e. we have used XYZ medication dispenser, or ABC remote support vendor, etc.)
Up to this point which groups have had access to education or professional development on enabling technology integration for the people you support?
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select all that apply
If you were to obtain Tech First Accreditation, what is your goal increase (number or percentage) at the end of year one of those being supported by Enabling Technology?
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List 3 barriers and solutions to this goal
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List three barriers that have, or will impact, your transformation to Technology First, then note solutions you've implemented and/or sources you would access to support a solutions-based approach.
Date of Submission
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MM
DD
YYYY
