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Communication Passport: IR Sample Communication Passport

The following information has been organized in such a way as to be folded into a brochure when it has been printed from the downloadable Microsoft Word® document: IR Sample Communication Passport

Problems with my wheelchair:

If my power wheelchair is not working, you can push it by changing it to manual operation. To do this:

  • Look for the yellow v-shaped bars on the sides of my chair. There is a small black lever underneath. Push them down. You can now push my chair.

 

My Communication Device

Please read the page in my binder that is in my bag on the back of my chair to help me use my computer.

Arrangements

Please read these questions aloud and I’ll communicate “Yeah” when you say what I want.

  • Do you want me to call about your transportation? If Yes, my registration number is on my information page in this wallet.
  • Do you want me to tell you when your transportation arrives?
  • Do you want to make another appointment?
  • Do you want me to write down the information about your appointment?

Passport

Introduction and how I communicate

My name is (first name).
I have difficulty speaking but I can hear and understand everything you say.

This is how I communicate:

Yes: I nod my head and say “Yeah”.

No: I shake my head and say “No”.

I want to say something: I use my voice to get your attention. I will speak. If you do not understand me use my maroon communication book. It is in my bag at the back of my chair. Or you read the page in my binder that is in my bag on the back of my chair to help me use my computer.



Things to know when you are communicating with me:

Please do the following when you are communicating with me:

  • Talk to me like an adult.
  • Speak directly to me, not to the person who may be accompanying me.
  • Give me time to communicate. Using a computer with a single switch takes more time than speaking.

Please note:

  • I make my decisions.
  • I need you to respect my privacy at all times. Do not discuss issues with other people who may be accompanying me unless I give my permission.
  • I need you to keep me informed of everything you are doing.

If you think I need assistance:

Ask me:

  • Is this an emergency? If yes, ask me if I need:
    • An ambulance?
    • Police?
    • Call someone?
    • Mrs. M at 111-1111
    • Tami 222-2222 ext. 2222

My information:

Name: IR

If I need help with Wheetrans:

Wheeltrans phone number is:
888-8888

My Wheeltrans registration number is:
33333333

Download this IR Sample Communication Passport. Note: You will need Microsoft Word® to view and edit this document.

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