Name
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First Name
Last Name
Email
Phone
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We're applying for accreditation for:
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Please list division(s), department(s), and/or region(s) if you checked those options in the question above:
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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
Number of I/DD support coordinators employed within the organization, department and/or region working towards the ET Credential or Navigator Certification
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Number of I/DD supervising/managing staff having oversight of those support coordinators within the organization, department and/or region employed within the organization, department and/or region working towards the ET Credential or Navigator Certification
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Number of I/DD leadership/directors (affiliated with support coordination) within the organization, department and/or region committed to the leadership track (courses, etc.) of accreditation
Number of Mental Health/Dual Diagnosis support coordinators employed within the organization department and/or region working towards the ET Credential or Navigator Certification
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Number of Mental Health/Dual Diagnosis supervising/managing staff having oversight of those support coordinators within the organization, department and/or region working towards the ET Credential or Navigator Certification
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Number of Mental Health/Dual Diagnosis leadership/directors (affiliated with support coordination) within the organization, department and/or region within the organization, department and/or committed to the leadership track (courses, etc.) of accreditation
Number of I/DD Individualized Service Plans (ISP) that include that include HOME/RESIDENTIAL "community based settings" as defined by HCBS.
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Number of those ISPs that include technology as a natural support in the HOME setting.
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Number of I/DD Individualized Service Plans (ISP) that include that include SUPPORTED EMPLOYMENT "community based settings" as defined by HCBS.
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Number of those ISPs that include technology as a natural support in the SUPPORTED EMPLOYMENT setting
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Number of I/DD Individualized Service Plans (ISP) that include that include COMMUNITY "community based settings" as defined by HCBS (such as recreation, transportation, shopping, etc.).
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Number of those ISPs that include technology as a natural support in the COMMUNITY setting
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Number of Mental Health treatment plans that include "transition to community living" or "community based settings" (home, employment, and/or community)
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Number of those treatment plans that include technology as a natural support.
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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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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
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