Effective Communication: What does that mean?

June 25, 2019


What does it mean to communicate effectively with someone who is Deaf, Hard of Hearing, or DeafBlind? This session will begin with a brief review of the requirements in the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act, and the Affordable Care Act (ACA). Sign language interpreters, relay service, and captioning are only one piece of the puzzle when working toward effective communication - you are the other piece! The presenter will offer an insider's view on best practices and teamwork strategies to engage when striving for effective communication between hearing and Deaf, Hard of Hearing, and DeafBlind individuals. Case studies will be used to illustrate various approaches in achieving effective communication.

Speakers URL: https://www.accessibilityonline.org/ADA-audio/archives/110713

June 2019 ADA Audio Webinar: Effective Communication: What does that mean?



Thank you, Peter. Thank you for all the kind words. I guess I do owe you five bucks after this. Thank you, everybody for being here today, joining us for this session. As Peter said, I am, just advance to the next slide, I'm a sign language interpreter. I have been for more than ten years at this point in the Chicagoland area. I just finished my Masters of Science in Disability Studies from University of Illinois at Chicago. It's a picture of me on the slide on the right. On the left we have the agenda. I'll give a quick run-down of the orientation of laws that cover effective communication, we will go through deaf populations. There is various, deaf people are individuals just like everyone else, and with individuals, comes individual needs. What works for one person as effective communication may not work for another person. I always think that it is helpful to know basics about who you are dealing with, about various deaf populations, and what typically works for these populations.

We will go over a few of the accommodations options that are out there. This is not an exhaustive list. This is just most of the common ones, and which to use particularly in which kind of setting, with which kind of deaf people. We will look at some examples of effective communication in practice with these accommodations, and of course then we will do a conclusion.

I'm not going to cover the laws extensively in this session. If you are interested in learning more about the laws and their requirements for effective communication, please look at our other webinars on the subject in the archive. I do want to give a quick run-down so people are somewhat familiar of the various settings that we see these accommodations most commonly provided. We have the Americans with Disabilities Act, Titles, this should be Titles, I, II and 3. The Rehabilitation Act, section 504, and then the Affordable Care Act, Section 1557 which is the civil rights section of that law.

Next slide. Slide 12, so I think the most common question that I get when people really start looking at effective communication is, what does that actually mean? When do you know that communication has been effective? The way that I have understood this, the only way to really guarantee for yourself to know if your communication with people with disabilities, with deaf people has been effective, is when the patient understands the information, and how will you know that the patient or the client, I should say, has, how do you know that you have achieved effective communication is if you ask that person to repeat back to you what they have understood. This is not always going to be possible, it's very easy to do this in a medical setting, for example, but it is not as easy to do it let's say if you provide accommodations for a live theater production. You are not going to be able to ask your clients to repeat back to you everything they understood. But the point is, you should be checking in with your clients, with the deaf people that you are working with, check in with them and see how it's going, do they feel comfortable with the accommodations, are they able to access the information.

Going to the next slide, the Americans with Disabilities Act titles, should be Title I, 2 and 3, I apologize Title I is not on there. Title I covers employment. If you are employing deaf people in your place of business, titles II covers state and local government services, so this includes things like the state court systems, state law enforcement, any state services, social services that kind of thing, and then title III covers private businesses, nonprofit organizations that serve the public, so places of public accommodations, we are looking at private doctors offices and also theaters, places of entertainment, that kind of thing.

The Americans with Disabilities Act prohibits discrimination of people with disabilities in employment, state and local government services, public accommodations, transportation and telecommunications.

The Rehab Act, section 504 forbids public and private entities that receive financial assistance from any federal department or agency, which includes Medicaid, Medicare, and the Affordable Care Act insurance, so insurance bought on the marketplace, from excluding qualified individuals with disabilities or denying them an equal opportunity to receive program benefits and services. So any federal entity, so here it's the federal court system, federal agency providing services.

Then we have the Affordable Care Act. This was put in place to close the gap on any medical providers who were, let's say they were private medical provider that was only open to people with private health insurance, so they are not accepting patients with Medicaid, Medicare or insurance bought on the marketplace. Therefore, they are not accepting any federal dollars. But they are operating as a medical provider. The Affordable Care Act says if you are operating as a medical provider at all, you are required to provide accommodations to people with disabilities, which includes in section 1557 is the civil rights provision of the Affordable Care Act, and it requires if you have deaf patients, you must provide effective communication accommodations for effective communication.

Next slide. Primary consideration, you will find this in the ACA, as well as in title II of the ADA. Primary consideration is where a public entities, private entities are encouraged to honor the choice of the individual with the disability, the choice of accommodation. The individual with the disability is in the best position to determine what type of aid or service will be effective.

This seems like it should be common knowledge, of course. The deaf person will be the best to suggest which accommodations they need, if captions are going to work best for them in this instance or if a sign language interpreter is what they need. But you would be surprised how many assumptions are made that everyone can read, therefore captions might be effective. But we know that not everybody can read, or maybe the assumption is, oh, they are deaf, let's get them sign language but not everybody uses sign language. I have actually as an interpreter in my professional life, I have shown up to jobs that I was booked for by a doctor's office or a corporate office where I show up, and there is a deaf person there and they look at me and say I don't need you, I don't know sign language. The doctor's office or whoever is the provider had to go back to square one, and this was all because they did not talk to their client or their patient before the event happened. They didn't even bother to check in with them and say, hey, what accommodation works best for you?

Primary consideration is specified because it's what we just talked about, obviously, if let's say the deaf person says I want a sign language interpreter, I do not want captions. I do not want video remote interpreting, which we will talk about later. I want a live in person sign language interpreter, but maybe the location where you live, there is not a qualified interpreter anywhere in the vicinity. Maybe there is not one available. We would like to see that the provider has at least done their homework, found out that the preferred accommodation is not available, they can prove that they actually did look, and went with a secondary choice. I think a lot of people have felt in the past that they ask for one accommodation or the other, and the provider doesn't honor that request, they don't even try, they don't even look and they jump to whichever one is most convenient for them, and convenience does not always achieve effective communication.

I'm going to skip ahead, skip the next slide so now we are on surcharges, slide 18. Surcharges basically with all the laws under all the laws, Rehab Act, ADA and ACA, you are not allowed to charge the deaf person for those services. Unless you are exempted from the law, which is only private clubs, if you are, Native-American reservation or religious entity you may or may not qualify for an exemption but if you are covered under the law and accommodations are required, you are not allowed to charge the deaf person for those services. Next slide, okay. Now we are getting into deaf populations, and I'll spend a good amount of time here.

You will see on the right there is a picture of two boxes of crayons, box on the left is, looks kind of vintage, old-fashioned, and the labels on the crayons say things like hearing-impaired, deaf and dumb, lipreader, dummy, handicapped. These are old and outdated labels that we do not use any longer. Deaf-mute, deaf dumb, are old labels outdated. They are considered offensive. They are also misnomers because deaf people are not necessarily mute. In fact, most of them are not. Most deaf people choose not to use their choice though, because most hearing people cannot understand the vocalizations that they do have. Anyway, if you are working with deaf populations, the correct terms are deaf and hard-of-hearing. You will see that box of crayons on the right looks like a modern box of crayons, that have labels, deaf, signer, hard-of-hearing, deaf American, late-deafened, deaf/blind, seeing and coda. We will cover some of these in the next few slides. Credit to this artwork goes to Ann Silver who is a great deaf artist. Deaf populations we have deaf with lowercase d, and that is on purpose, it is not a typo. Hard-of-hearing, Deaf with a capital D, deaf/blind, or deaf and low vision, deaf disabled, and deaf, ASL, SL, ESL, which is deaf people who use ASL as a second language, and English is also a second language for some people, it may be a third or fourth language.

First we have deaf with a lowercase d. Generally, these are deaf people who do not use sign language. They do not identify as culturally Deaf. On the right you see the capital D Deaf. That refers to people who use sign language. They also identify with a community and a culture of Deaf people.

Little d deaf people do not necessarily culturally identify with that same group. These deaf people are often raised with an oral method which means they were raised being taught to lip read and speak. That is often problematic and we will talk about that later.

They may be late-deafened, so late-deafened people, people who become deaf with age, usually senior citizens, and if you have spent 65 of your, 65 years of your life hearing, and speaking, most people are not going to drop everything and start learning sign language at 65. So elderly people, our senior citizens, we know them to be deaf or hard-of-hearing, but not part of the Deaf community.

Then, little d deaf people also might identify as hearing-impaired. I just got through saying we don't use those terms anymore. But some people might. Some people might refer to themselves as hearing-impaired. But generally, that is going to clue you in to maybe what style of communication they often prefer, again don't jump to conclusions, but these are cultural nuances that as you work with these populations, you might pick up the clues.

Next we have hard-of-hearing in the middle. Hard-of-hearing people, and this is generally written with capital Hs, hard of capital H hearing, have some hearing, that hearing might only be possible with an assistive device such as a hearing aid, cochlear implant, FM system, what have you.

These people might prefer captions to sign language interpreters. But they do often use sign language themselves. There might be, they might be a little flexible in which accommodation that they prefer, depending on who they are with, and what the occasion is. Hard-of-hearing people often identify as culturally Deaf, culturally hard-of-hearing, as they regularly identify as being part of the Deaf community and Deaf culture.

A little fun fact or ironic I guess understanding is that hearing people generally when hearing people talk about others as hard-of-hearing, we consider their hearing to be, to have a significant hearing loss, right, when grandpa is hard-of-hearing, you have got to speak up because he doesn't hear very well. But if you are coming from the Deaf community when they say that one of their community members is hard-of-hearing, usually they say that to mean that their hearing is quite good. So it really depends on what perspective that you are speaking from. But that is just another cultural nuance that as you work with these populations, the misunderstandings of what people mean is possible, depending on if you are fluent in the culture or not. All right.

Now we have capital D Deaf and there is an icon of the two hands. This design, this logo here was originally designed by Ann Silver, the same artist that we saw do the box of crayons. It has been co-opted by the Deaf community, interpreting community and has become kind of a universal symbol for sign language, for sign language interpreting. This is a note to anyone who might offer various languages at your place of business, at your office, if you have one of those signs that has flags to denote every language service that you offer, you might want to use this logo, the two hands, people who need sign language interpreters will recognize that as a marker for ASL, for offering American Sign Language.

Capital D Deaf people, they are primary and preferred mode of communication is usually sign language. It doesn't mean that they will never request captions or English, but their primary and preferred mode is usually sign language interpreting or sign language. They are visually oriented group, and we will talk about this more, why this is important, but they are a visually oriented population that really depends on visual aid, visual sightlines, everything around that is important to think about when you are working with these populations, they identify as culturally Deaf and the linguistic minority. A lot of deaf people you will hear them say, I'm not disabled, I'm Deaf.

And I'm a linguistic minority in the United States. So they really don't identify with being disabled, so much as we are a people that uses a different language, just as you have other linguistic minorities in this country, Polish, Spanish, etcetera, you have sign language users.

Another cultural note I have in here is straightforward communication. Capital D Deaf people have, they are dealing with a legacy of miscommunication, because they don't use a language that is understood by the mainstream, because there is kind of this legacy out there of poor education, lack of services, lack of access to language, even at home. Most Deaf people are born to hearing parents, and the statistics of how many hearing parents learn sign language to talk to their kids is quite poor. So even at home, they are not, they are often misunderstood. There is often lots of miscommunication happening. So, culturally, it has developed that the style of communication within the Deaf community is very straightforward. It is not, there is no sugarcoating. There is no kind of niceties, and granted I'm talking in sweeping generalizations here but culturally, it's in hearing culture it might be considered rude to say things like, oh, I haven't seen you in a while, you have gotten fat. But in the Deaf community they are stating the facts. This is what they see. It is not considered rude. It is a style of communication straightforward communication, but when this really matters with working with deaf populations, for example, an employer might have a meeting with a, a hearing employer might have a meeting with a deaf employee and say something to the effect of, if you are late again, we will have to re-evaluate your position here at the company. In the hearing world, we might understand that to mean, if you don't straighten out your attendance, you might be fired. In the Deaf world a sentence like we will have to re-evaluate your position here it won't be communicated the same in ASL. They would go straight for the direct meaning of that message, if you are late again you will be fired, if you are late again there will be action taken. Keep that in mind when you are talking to people who identify with the Deaf community. If there is something sensitive that you need to discuss with them, think about the ways that you are trying to communicate with them, and what is going to be the clearest route to take.

DeafBlind populations, this is also again not a typo, Deaf and then no space, capital B blind.

DeafBlind community also identifies as a community. They sometimes will identify as a subgroup within the deaf community. Sometimes they identify as completely independent community, separate from the deaf community. There are still some cultural deaf tendencies there. But the DeafBlind community, remember the deaf community is visually oriented people but if you are blind or have low vision, you are not going to be visually oriented. DeafBlind community usually identifies as a tactile community. So everything revolves around touch. Tactile interpreting, kind of a crude visualization of that is if you think of the most famous scene of any Helen Keller story, where Ann Sullivan her teacher signs water into her hand. That is tactile interpreting, where an interpreter is signing and a DeafBlind person's hand is on top of the interpreter's hand. Sometimes instead of the DeafBlind person's hand right on top of the interpreter's hand, you will have them do what is called tracking, the deaf/blind person's hand actually stays on the forearm of the interpreter, and helps them to track where the hands are moving to. So maybe these DeafBlind people have a little bit of vision, but they need to track where the hands are going, so that they can direct a little bit of vision that they have to where the interpreting is happening.

Of course, DeafBlind people are going to be the best ones to tell you what exactly they need. There are interpreters who do this kind of work, there are also sign language interpreters who prefer not to do this kind of work or haven't had proper training in this kind of work. That is another thing to think about when you are thinking towards getting accommodations for DeafBlind people. There is also pro tactile interpreting, and this has been around for a while although we are still, it has been a slow learning curve for the interpreting community to be trained in this. Sometimes the deaf/blind community to have access to this as well, to have access to training on it themselves. Pro tactile interpreting is like tactile interpreting 2.0. Instead of just having the DeafBlind person's hand on top of the interpreter's hand, the sign language interpreter will use both hands but do more sign language on the arms or perhaps sometimes even the body of the DeafBlind person. A lot of times you will see multiple interpreters interpreting for one DeafBlind person at the same time. One person might be the primary interpreter, giving the language, giving the actual sign language. Another interpreter is behind the DeafBlind person giving them environmental cues on their back and shoulders. So they can do signals on the back and shoulders to say, somebody has just entered a room. Now people are laughing. People are smiling. People are sleeping. People are leaving the room, etcetera. You might even see a third interpreter giving the DeafBlind person feedback on whether the hearing people are nodding, if they are still listening, and so I'll have a picture later where we can see this in use.

DeafBlind people might use Braille, they might not, depending on their tech savviness. They might use electronic communication better than they use Braille. So just check in again with your individuals, see what is best for them. You might need to think about environmental adjustments when you are working with DeafBlind people. Sometimes light and lighting is very sensitive with DeafBlind people, if something is bright like if you have a window as a source of natural light, it might obscure the vision that DeafBlind people do have. So making sure that the environment is I guess effective for them also, it helps sometimes if people wear dark colors instead of a white shirt, a white shirt or light colored neon colors might be a problem for some DeafBlind people. Just check in with them again. Also DeafBlind people sometimes bring or request or use a support service provider, abbreviated SSP, support service providers are not interpreters. Sometimes they do know sign language, but it's a little bit of a different job and responsibility. SSPs are people who might lead the DeafBlind person around a physical environment. They might lead them to the bathroom. They provide services outside of the interpreting requirements.

I think that, and if anyone wants to correct me if I'm wrong, but I think that Seattle is the only place currently that has included support service providers in their laws as an accommodation required for DeafBlind people that so far support service providers are not recognized in the same ways that sign language interpreters are. Seattle is way ahead of the game in their DeafBlind services as reports. I think we could all take a lesson from them. But anyway, support service provider SSPs, some interpreters will also provide the service, but you really do have to check in because it's kind of an individual basis, whether the person has the right training.

And whether the DeafBlind person wants that or not, they may not want the SSP at all. Deaf disabled, so this is deaf people who might also have a physical disability or an intellectual disability. Sometimes we see deaf disabled as a result of language deprivation. There is recent work on this within the last ten years, there is a lot of studies that is going on regarding deaf people who are not given access to language in the first ten years of life, and how this sets up barriers for them in the long term. It might be cognitive barriers, might be something else linguistic barriers, but unfortunately, it happens more often than you think, and not just in this country. It happens worldwide. Let's see. Deaf disabled people, they might work with an advocate or social worker, a lot of times in a doctor's office you might see a group home or social worker accompany a deaf person to the appointment. This is not always the case. The interpreter is usually not a social worker or an advocate. The interpreter is usually hired separate of that situation, so just be sensitive to that. Don't assume that an interpreter is an advocate for this deaf person or a social worker. We will talk about that a little later.

Deaf people who are also disabled are sometimes isolated from common knowledge. If you think about living in the hearing world, hearing people get up in the morning, turn on the radio, get the news from the radio while they are doing other things. They talk to their family, get updates from their family. They go to school, they listen to the radio in the car. They overhear language or overhear conversations in the classroom, in the office, in the doctor's office, and are just constantly getting the newest information, what is going on in the news, what are medical advancements and updates. Deaf people are not always, they don't always have access to this in the same way. When you are deaf and disabled, if you are living in a group home for example, you might be, you might have further barriers to that. Sometimes deaf people are living in a group home with no other person in the group home who knows sign language. So they are really kind of isolated from this flow of communication and common knowledge, and if you are working with deaf people who are disabled, you are going to want to think about that and keep in mind that what you think is common knowledge, what you think is common sense, is not a privilege for deaf people who are isolated or have other barriers.

All right. Deaf users of ASL as a second language, and English as a second language, usually we see these as deaf immigrants, coming to this country. You might see them in the immigration office, or in educational situations, or doctor's offices, I mean anywhere, everywhere else. Sometimes they do not use or they do not yet know ASL, depending on their experience here in America. Sign language is not universal. American Sign Language is used in America, some parts of Canada, some parts of Mexico. And Ghana in Africa.

I've been told, in the Philippines, but I've had other people tell me that is not true. It's also used in Belize. But if you as American wanted to go to England, for example, if you are hearing, we can communicate with them, right? Because they speak English. But their sign language is completely different, completely different alphabet, different grammar structure, different signs. It's impossible to translate between, well, you can translate between the two but it's impossible to compare the two. They are completely different languages. That goes for almost every other country around the world, Kenyan sign language, Chinese sign language, Japanese sign language. They are all very different. When deaf people are coming to America, they do not yet know ASL. They might also not have any English experience, and so to think about that in working with them, in these situations, using a deaf interpreter and I'll define that in a minute, using a deaf interpreter is strongly encouraged.

Things to keep in mind, illiteracy, in the deaf community, because access to education is not always what it should be, deaf people don't always read and write at a privileged level I guess, even those who have gone to college might still struggle with reading and writing. I think the statistic is that a person, deaf person who's graduated high school might still read at a fourth grade level. Of course this is a sweeping generalization, this is not going to be everyone you meet. But if you ask a deaf person, can I give this to you in writing, or here are instructions or can you read this form and sign it? If they say anything to the effect of, I'm not so great with English, I'm not so good at reading and writing, what they are really meaning a lot of the time is they are completely illiterate. I struggle to say that because they might be able to answer very simple questions like what is your name, what is your birth date. But if you are handing them a consent form for a procedure or surgery or if you are handing them a mortgage contract for a home, or anything else, that is some complicated text that hearing people might even have trouble with, but then being deaf, there is further barriers. So thinking about that, and especially with that sentence, I'm not so great with English. In my experience, that has been code for I really don't read very well. Then you think about how would you conduct business with any person, not just deaf but any person who is illiterate. Think about applying those techniques here.

Limited peripheral learning, we talked about that a little bit, especially with deaf people who are disabled. But again, that comment, that flow of common knowledge or news updates that is constantly accessible in the hearing world is not to a deaf person. Information that seems commonplace to you is not always going to be commonplace for a deaf person. If you can take the time to make that direct communication with the deaf person, you are going to be a lot better off. Then family networks, this is pretty understood nowadays, I feel like, but even maybe 20 years ago, when hospitals or whatever facility were more stringent about how you are related to this person, whether or not you have access to be with them, in the deaf community, because of the language barriers even within family, blood relations, family networks and family structures in the deaf community are often compiled of lots of friends from the deaf community who are not necessarily blood relations, just to keep that in mind.

All right. For accommodations for effective communication, I'm not sure if -- okay. Sorry. I advanced one screen ahead. Looks like animations are not going to work. But accommodations for effective communication, it depends. The images that you are not going to be able to see here because there was a animation behind it, if you have, if you are needing accommodations for a doctor's office, it is going to look very different than if you are trying to provide effective communication for a theater or if you are trying to provide effective communication at a sports game.

We will get into some of these following. But before we do, I do want to stress that lipreading and the assumption that deaf people can lip read is a myth. Here I have on the left that lipreading is an effective mode of communication for most if not all Deaf people. The fact of the matter is, that the average rate of accuracy for lipreading is 12.4 percent. So out of everything that you are saying, deaf people are catching maybe every 8th word. Anything beyond 30 percent is an outlier. I have met one deaf person in my whole life who can lip read almost perfectly, but of course, it also depends on, and I have these bullet points here, that this deaf person, is knowledgeable about the context of the subject, usually has some residual hearing, is participating in a setting one on one with somebody, so they are not sitting at a conference table where a conversation is quickly bouncing between various people at the same time. They are speaking one on one, facing somebody else. The communication is happening with eye contact, it is one thing to sit across from somebody and try and lip read them. It's another thing to try and lip read someone while they are turning around and facing the whiteboard and writing something and turning back to you and then talking to their, into their computer and etcetera, etcetera. Clean-shaven face, those men with giant beards sometimes lips and mouths are hard to see. When people speak with accents, the shape of their mouths is nonstandard, which also affects the ability for people to lip read. Standard mouth shape and speech production, sometimes even if people's teeth are not straight, this can affect the shape of the mouth and so trying to lip read that can be quite dubious, and then it also requires an excruciating amount of patience because if somebody doesn't understand, then they might ask you to repeat yourself, and clarify in other ways, and it can take quite a long time.

The point of this slide, if you remember nothing else today, is that lipreading is a problematic expectation of how to communicate with most deaf people.

All right. So as you think about working with these populations and providing accommodations for effective communication, you want to think about who and what is going on, who and what is involved. How often, and how soon do you need this to happen. Who and what, who is requesting? Who is that deaf person, do you know anything about them? Do you know their style of communication? Do they have preferences? Are they flexible in their preferences depending on the situation? Are there multiple deaf people within one event? Get to know your clients. What are they requesting? Do they have a preference? Do they request a sign language interpreter, did they request captions, did they request something else? What kind of an event, obviously, that is pretty straightforward, but are you meeting with this deaf person at a corporate office, are you employing them, are you, are they a medical patient, are they coming to your entertainment event, etcetera. Is the situation going to be gender specific? If you are hiring, for example, if you are hiring a sign language interpreter, and it is for, who knows, an appointment at an office like a Social Security office, that is not going to matter so much, versus if you have a deaf woman going for a mammogram, or an Ob-Gyn appointment she might want to specify she only wants a female interpreter, and of course with men, if they are going for a physical, they might require a male interpreter. Can services be remote? We will talk about this when I give examples of what kind of accommodations are out there. Sometimes you can get a captioner like we have today, who is remote, so the captioner is not in the very same office as I am. But as long as they are able to hear me, they are able to do their job as effectively as if they were sitting in the office with me. And this makes it easier in some instances, especially when there might not be a captioner anywhere in my town, but I still need those services, and they can be remotely plugged in to whatever event that is going on.

How often, is the event ongoing? Is this a classroom situation? Maybe you work at a college and you need a sign language interpreter for this class on Thursday nights for an entire semester. This is really key in providing the best most effective accommodations or effective communication possible. If you think of a classroom situation, and you book one sign language interpreter or one captioner for the entire semester, that person is going to be able to learn along with the student, and provide accommodations or a product that is consistent with the information, they have a good rapport with the student. They can, they agree on signs or abbreviations of things that they know for their purpose within this class, signals this concept or that concept. If you have a class that meets once a week, but you don't hire an ongoing interpreter, and it's just kind of ad hoc piecemeal whoever is available, every week there is a new interpreter, and that interpreter doesn't have any background knowledge or context of what has been going on in this class, it's actually going to be quite difficult for them to provide as good an accommodation as with the interpreter who is going all the way through.

So, if you have an interpreter or captioner who is a new one every week, it is not going to be as good as if you can employ one for the entire semester. Sometimes you can be strategic, is the event ongoing and how often you are using the service, would it actually make more sense for you to figure out how to get someone on staff, depending on how often you are using the services, so here in Chicago there is a hospital who actually does have on staff interpreters, because the Deaf community knows that this hospital provides these services, and they actually rallied together and they will all use this one hospital, which meant there was more deaf patients going to the hospital to the point where the hospital said, actually, this makes more sense if we just have someone on staff. It makes more sense from a consumer perspective of providing the best services. It also makes more financial sense, sometimes. So it depends on your business model, on what you are trying to achieve, how often, and again how many consumers are requesting the same service. If it's just one person once in a while, then obviously it's going to be on an as-needed basis. But maybe it's more than that. Maybe it's seasonal and you can develop a relationship with the same service provider with the same accommodation service provider on going, so that you don't need to hire them on staff but you know who to go to every time you get a sense of what works, who the qualified people are out there. Then how soon, is this an emergency? Are you working in an emergency room and you need to make sure that you have a strategy in place to be able to request accommodations as soon as possible, at the drop of a hat. Even if the deaf person comes in at 1 in the morning, do you have a strategy in place? It's unfortunate, but it happens all too often, where an emergency room for example does not have a strategy in place, and when the deaf person comes in with an emergency, they are already stressed out, of course, because they are not feeling well, and in addition to that, now they have to deal with an emergency room with employees who don't know what they are doing, they don't know how to request an interpreter, they have never gotten this before, they don't know who to call, which only adds to the stress of the situation.

If you do have a requesting policy, let's say you are not an emergency room, maybe you operate a theater, and you have, or an office of some sort where you are seeing or you are making appointments, maybe you establish a policy for making requests, and knowing that, it often takes a good two days to find a interpreter if you call an agency and put in a request. Sometimes it takes at lease two days, some places in the country it is going to take more than that. There is not enough sign language interpreters and captioners to go around. You might have a policy that says we require 48 hours’ notice, it really depends on a case by case basis what service that you are providing, and if you allow the hearing world or the able-bodied world to make emergency requests, then you also have to respect that when deaf people do it as well. You can't say that hearing people can make last minute requests, but deaf people cannot, because of the accommodation requirement. If hearing people are able to do it, then deaf people can do it too. And you have to have that emergency requesting strategy in place. Then also in regards to how soon, what does the landscape of service providers in your area look like. So in Chicago we know that there are not enough sign language interpreters to go around. I encourage all the people that I can to make their requests at least a full week out. If you make it under a week, there is no guarantee that you will get a sign language interpreter. I know that in many places in the country, it's very similar. So if you start working in this area a lot, you might start to understand the lay of the land, and how many service providers are out there, how quickly do you need to get that request out there, in order to guarantee services.

Okay. Now we will talk about the accommodations themselves. I won't read this slide word for word. But it's basically talking about the qualifications of sign language interpreters, how do you know that somebody is qualified. On the right, I have three pictures here. These are pictures unfortunately of three people acting as interpreters who were unqualified for the jobs that they were doing. The one on the top, this guy, this was in Florida for one of the hurricanes, and they decided that the, the news station decided they wanted the sign language interpreter in the broadcast, and so instead of calling an agency, instead of calling for a qualified interpreter, somebody said, I think my cousin knows some sign language. He is a lifeguard. Let me call him and see if he is available. This guy in the bright yellow polo shirt shows up to the news station and starts waving his hand around. He made it all the way to Trevor Noah so this is just to impress upon you that qualified interpreters come with credentials usually. The credentialing process is state by state. There might be some differences, if you are working in Illinois versus if you are working in New York. But again, the second picture, the woman there is also, she was a bogus interpreter who just waved her hands around in the air and I think was prosecuted for fraud. The guy on the bottom, the man on the right with his hands in the air was also a fraud and this was Nelson Mandela's funeral. I want to stress that unfortunately it is common that sign language interpreters if they cannot produce credentials for you, they are usually what we refer to as a signer. They might know some sign language but that doesn't mean they are going to be qualified to provide effective communication in the situation. I caution you to be careful about using people who are signers or people who say they know a little bit of sign language, as an interpreter it might actually backfire on you, and you are not going to be able to defend yourself in court should it come up that you tried your best to provide a qualified interpreter.

I do have a link here, credentialed interpreters differ state by state. You can find state requirements at the website. It's RID.org and the rest of the link is there. But RID is the registry of interpreters for the deaf. You can find that your state requirements as well as a directory of interpreters working in the state who are licensed.

All right. Sign language interpreters, here is the logo of the two hands. If you Google sign language interpreter logo, you can bring up this image, and who to find. You can find them, find sign language interpreters through agencies, if you look on line, type in your city or zip code, and then sign language interpreter agency, hopefully some will show up.

Or you can direct a contract with an interpreter, you can find them sometimes on a state directory or again RID.org, that directory, does the deaf person have a preferred interpreter, sometimes it's nice to, if they have an interpreter that they have worked with in the past, who's worked well for them, they might have that request. It is not always guaranteed that the interpreter will be available. But it's nice to honor that request when it's made. If you have any prep material, it is, interpreters love to get that information ahead of time, so that they can prepare for their job. If they can read through, if you are giving a speech, or if you are teaching in a classroom and you have lecture notes that you have prepared, sometimes universities have like what we are using today, they have Blackboard or they have Moodle or canvas, any of those on-line software portals that are used with students to communicate about classroom, sometimes it's nice to get the interpreter access to that as well, so that the interpreter can take a look at what is going on in class and prepare in that way. Also, if there is a medical appointment going on, it's nice to give the interpreter information about what exactly is happening, what is expected to go on that day. Is it a surgical consultation? Is it a diabetes checkup, or is it an actual procedure? Interpreters are covered under the same HIPAA laws, we are also covered under our own code of ethics, confidentiality laws and rules. There shouldn't be any, I guess, anxiety about sharing that information with the interpreter. In some cases it's really imperative, as an example horror story, one of my colleagues said that she was booked for an appointment where the information that she got was eye exam. That was all the information that was given, because the eye doctor didn't feel comfortable providing any further information about the patient or the date, I guess the appointment. When she got there, it wasn't an eye exam. They were doing eye surgery and removing the eyeball, which she would not have accepted this job had she known, all the gory details. For myself, there are some times where I would faint at the sight of blood. So if I know that there is, that a job is going to include blood, I might not take that job. That is something that you are going to want to include, when you are booking that interpreter or whatever accommodation. Let's see. Don't engage the interpreter on the job. Standard practice when you are working with an interpreter, it's I wouldn't say ignore the fact that they are there, because sometimes you do need to work directly with the interpreter to make sure that communication has been effective. But don't talk to the interpreter as if they are there socially. Also, when you are talking to a deaf client, speak directly to the client. Don't use the, tell him I said this or tell her I say this. It is just considered rude. Also sometimes it can be confusing who you are trying to talk to. Another thing is if there are papers, if there are files that are being passed to the deaf client, resist the urge to pass them to the interpreter. I know sometimes it can get confusing because you are hearing the interpreter's voice. I can't tell you how many doctors have tried to give me medical files of the patient when they should have been handing it directly to the patient. Then also, the biggest no-no in working with interpreters, is please do not tell the interpreter, don't interpret this and then go on to say something that you didn't actually want the deaf person to hear. It is obviously rude, interpreters most of the time will continue to interpret. So everything that you didn't want them to say just got interpreted anyway. But then also, sometimes people will think that they can turn the interpreter off, and then talk in front of the deaf person as if the deaf person is not there. And again, you wouldn't do this with a hearing person. If there really is something that you need to talk to somebody about confidentially, you need to either leave the room or have the deaf person leave the room. Don't talk about them in front of them like they are not there.

Strategizing how to use your sign language interpreter properly, if you are, for example, in the top image I have a group of business people sitting in a circle. If you have a setup like this where the conversation is bouncing around the circle or conference table, there is multiple people speaking, it's helpful to introduce yourselves every time you start talking. It may seem like it's a little excessive, but it helps the interpreter to signal to the deaf person who is talking now, because otherwise, it can get confusing on who is saying what, if an argument breaks out, who started that, who is responding. Even if it's not an argument, if it's just a regular discussion, it's very helpful to introduce your name every single time you start talking. Because the deaf person is watching the interpreter the whole time, if they look away from the interpreter to search the circle to figure out who is talking and then look back to the interpreter, they have already missed out what is being said during that time that they looked away from the interpreter.

Always use the microphone. Interpreters and captioners often roll their eyes when there is a conference full of people, they are supposed to be using a microphone if they want to make a comment or ask a question, and they don't want to wait for the microphone or maybe there is a problem with the microphone, and they say, oh, I'm loud enough anyway, I'll just talk. That's not, microphones are not just for amplification to be nice or convenient. It's actually an access issue. If there is a microphone set up, it is there usually for access purposes. You don't know but there may be somebody using the FM system. There might be a captioner, remote captioner who is depending on audio coming through that microphone, in order to be able to do their job. Same thing with the sign language interpreter. You may think you are loud enough, but that might not be true. It might not be loud enough to be heard over the rustling of paper or bodies or anything else. So please get out of the habit of saying, I'm loud enough. Know that the microphone is an access issue. Just wait for it. If there is a problem with the microphone try and troubleshoot it before just barreling on through with whatever you are doing, because the deaf person is going to be left out.

Please caption your videos. Even if you have a sign language interpreter in your conference or in your classroom, it's not the same to assume that a sign language interpreter can interpret a video or a movie the whole way through. You may think, it's just the three minute video. But the deaf person, first of all has to split their focus, between looking at the interpreter and looking at the video, it's hard to watch both at the same time. Videos sometimes can be quite complicated and fast, for an interpreter to be able to keep up with. It is much better access, it is more effective communication to caption your videos instead of depending on a sign language interpreter. Also careful with the lighting, so this picture on the bottom here shows some kind of classroom situation, the teacher is there in the background looking at a lighted screen like a smart screen, and the lights are off so that everyone can see their computers and the screen. This classroom is pretty dark and if you have a long time going on with the darkened classroom like this and the sign language interpreter trying to work and the deaf person trying to depend on that interpreter for information, it's quite tiring on the eyes and the brain for that deaf person to try and figure out what the sign language interpreter is saying in the dark. Be careful with lighting, if you do turn off the lights in your conference room or classroom, to be able to see screens better, make sure that you still have enough lighting on the interpreter for the deaf person being able to access communication.

The top left picture shows a typical setup in the doctor's office and the patient room. You have the doctor who is sitting on his stool taking notes. Next to the doctor is the sign language interpreter. Then across from the interpreter and the doctor is the deaf person. For any three person situation or more people, but generally you are going to want the interpreter to be right next to the person who is speaking the most, and the deaf person obviously will be across from the interpreter, for sightlines, for effective communication, this is going to be the best setup.

I stress this because sometimes if people are new to the process of working with interpreters, it's uncomfortable for them to have somebody standing right next to them, feeling like they are breathing over their shoulder. But this is most effective setup.

If you look down the image on the bottom left, this reiterates that same idea, this time it's at a table, instead of in a doctor's office. This is a table with four chairs. The hearing person is the blue face, the interpreter is the pink face, sitting next to the hearing person, and the deaf person is across from the interpreter. The deaf person could sit in either one of those chairs, the one on the left or the right. But again stressing the point that the deaf person sits across from the interpreter and the interpreter sits next to the hearing person. This is so the interpreter can hear the hearing person the whole time but also so the deaf person can catch the hearing person's body language, facial expression, within the same sightline as the interpreter.

In the top right corner, there is the podium with, I think there was Mayor Bloomberg and the interpreter sat next to the podium as the mayor talked about Hurricane Sandy. This was one of the first times that we saw a large scale press conference like this include a sign language interpreter and keep the interpreter on screen throughout the press conference. Unfortunately, what happens often, even as recently as the last hurricane season or fire season in California, sign language interpreters are hired for press conferences, they are set next to podium and a guy or the person doing the filming zeros in on the person speaking at the podium and cuts out the interpreter, which completely destroys the point of providing the interpreter in the first place. If you are going to provide an interpreter at the press conference, the goal is to include the interpreter in the broadcasted message so that deaf people watching TV or Facebook live or however this is being broadcasted can access the sign language taking place. Then on the bottom right we have an aerial view of a theater, the stage is at the bottom of the image and then you have the rows of seating. This is a common placement for interpreting services, but it's not the only option. But you might see this most often, the pink Smiley faces are the interpreters who are placed either on or just off the stage on the floor in front of the front row, and off to one side of the stage. Deaf people are then going to be seated a couple rows back, not in the first row, not right in front of the interpreter. It is too close. It is not a good sightline for them to try and look at the interpreter from six inches away. The deaf people are going to be seated a couple rows back at least. Then even further off to the side, so when they look at the interpreter they can also look through the interpreter to the action on stage. If you have those deaf people seated in the center, then the interpreters are off to the side, when the deaf people want to look at the interpreter, the deaf people want to look at the interpreter, they would have to break focus from looking at anything on the stage, to look at the interpreter and then return their eyes back to the stage. It is not good sightline. Think of the green arrow is the sightline, when you are placing interpreters, make sure you think about that.

I'm going to speed through some of these slides because I see we are running lower on time. I want to have time for question and answer. This is a conference table setting, if you are using a screen on one side of the conference room, you might want to have your deaf person on that side of the screen, interpreter across from the deaf person. The interpreter could stand on either side of the screen for best sightline, versus if you have, if you are not using the screen, and the hearing person is leading the meeting, and you have the interpreter seated right next to them, the deaf person can be adjacent or across.

Using deaf interpreters, deaf interpreters are deaf language experts. Deaf interpreters typically are people who are native users of sign language, they also might have a more nuanced understanding of gesture, and communication that goes beyond standard American Sign Language. You would work with a deaf interpreter or a CDI, certified deaf interpreter in tandem with a hearing interpreter, so the communication goes from the deaf person to the CDI to the interpreter to the hearing person, and then back again. You would usually use deaf interpreters in press conferences or with people whose first language is not ASL or English. Deaf people with intellectual disabilities, deaf people with CP or other mobility barriers, as language models for children, with DeafBlind individuals and again in emergency briefings. This picture on the bottom left, you see two people using pro tactile interpreting. You see them doing action on the forearm of the DeafBlind person. If you want to get a better take on deafblind interpreting look it up on YouTube. There is some spectacular videos on it, especially one boy, DeafBlind boy whose family or I guess friends is doing pro tactile interpreting for him to be able to participate as a soccer game, he is watching a soccer game.

Video relay service is live interpretation on a phone call. You look at the image down below, the deaf person is using the video screen, they can see the interpreter. The interpreter is sitting in an office in a call center, anywhere in the United States. They can see the deaf person on the video screen and talk to the hearing person on a headset so the hearing person is using a telephone. Think of VRS as telephone service, if you want to call a deaf person, versus VRI. Video remote interpreting is when you are in the same room as the deaf person, and you want to talk to them, you have no live interpreter, you don't have an interpreter physically present, you can remote in a sign language interpreter on a video screen. You see the medical provider here, video screen interpreter next to her, and the patient in front of them. Video remote interpreting is for needing interpreting services in the same room, not on the telephone.

VRI can be used on an actual VRI machine, you can remote them in on a tablet. Sometimes on any mobile device, but not a smart phone. That is too small to be accessible.

I'm not going to -- I'm going to pretty much skip this slide, if you want to review it, these are the specifications from the ADA on the requirements for using VRI. If these four bullet points are not met, VRI is not acceptable as an accommodation for effective communication.

CART, Communication Access Realtime Translation. This is when you have a captioner like we have today providing live captions for your event, can be used remote. CART people are not usually as mobile as an interpreter, because they come with equipment. In this image you see they have a machine they are using and it's connected to a computer, sometimes it's connected then to a projector, going on to a screen. An interpreter is able to follow deaf client around the room, or around a building. A CART person is not able to pick up their machine and portably move throughout a building. CART can be projected onto a large screen. You can see it in the picture on the right. They are using a large screen. Or it can be plugged into or I guess remoted into a smaller laptop computer, a smart phone device, a tablet, it's pretty cool what they can do with technology nowadays.

Here again you see CART shown on a large screen on the left. You can see I think that is Bill Clinton speaking as well as the sign language interpreter is also shown on the screen, with the CART captioning happening at the same time on the same screen. Sometimes you will have it on a separate screen, as you see in the picture on the left.

All right. FM loop system, for large auditorium or conference style rooms, in more modern buildings there is usually a loop system installed in the building, check to see if this is actually included in wherever the space you are using. It's an induction loop that is placed along the outside of the building or outside of the space, the room. Then people either already have their own device that they can turn on and access that loop system, or sometimes hearing headsets can be distributed, where people can use them and access this FM loop system. If you are using the FM loop system, sometimes you have to have specialized microphones. Again make sure that you are using those microphones. Don't assume that you are loud enough. It is not the same. It doesn't work the same way.

Open and closed captions, if you are showing films and presentations, classes, cultural events, make sure you caption your videos. If you make films for businesses or organizations, caption those videos. Plays, scripted live performances can be done for free, if you have enough time. But usually you are going to want to hire somebody who knows how to do this professionally, who can project those captions. And then if you don't want to caption your own videos, there are third parties out there who offer to do it for you at a cost. But they also know what they are doing.

Let's see. Also in terms of working with deaf populations, any visual aids that you can use are always going to be a boon. So whether it's a visual chart, like we have here showing a water cycle, or an image, especially in medical situations, it might help to show a deaf person an image of the body or body system that you are talking about, so that you can show them directly on the image what you are talking about, and whatever the issue is. Written communication, sometimes hearing people think I can just write back and forth with the deaf person. But this is really for short communication needs only. Are you going to conduct your entire appointment through written communication and writing back and forth? And if you think about it, are you going to provide the same communication through writing that you would if you were able to talk to this person or use an interpreter or captioner. Usually hearing people don't. Usually what happens with written communication is people get frustrated because it's taking too long, or we can't understand each other's writing or this, that and the other thing and they shorten the communication which makes it not as effective. Can people read your writing? Can you read theirs? This process is slow. Think about how much time do you have.

All right. So in conclusion, again, think about who your Deaf client is and what are their communication preferences. Strategically plan accommodations services. Work with the accommodations provider prior to the event to make sure that you are set up properly. Effective communication is case by case. Again, what works for one person is not going to work for everyone. And you are ultimately responsible for ensuring that communication has been effective. So whichever route you take, make sure you are checking in with your deaf client to make sure it has been effective for them, and if there are adjustments needed to be made, you can go ahead and make them.

All right. Thank you for your time. I guess we will open it up for questions now.

Peter Berg

Thank you very much, Shannon. Michele, if you can come in quickly and give our phone participants instructions on how they can ask questions, please.


I sure can. Ladies and gentlemen, if you have a question at this time, please press star and then the number 1 on your touch-tone telephone. If your question has been answered or you wish to remove yourself from the queue, press the pound key. If you have a question or comment at this time, press star then 1.

Peter Berg

While we are waiting for that, Shannon, there was some confusion about the application of section, 1557 of the Affordable Care Act and just for reiteration, that provision applies to healthcare providers that receive funds from the U.S. Department of Health and Human Services programs that are directly administered by HHS, or the health insurance markets or plans that are offered through those markets. That is who is subject to the 1557 requirements. To let folks know, as you know, Shannon, the U.S. Department of Health and Human Services HHS just last week published a proposed regulation that is designed to revise the implementation and enforcement of section 1557 of the affordable healthcare act. You can read that proposed rule and get information on how to submit a comment on that proposed rule by visiting regulations.gov and searching for section 1557 of the affordable healthcare act.

Shannon, if you can talk about that, in many instances you have multiple layers of laws that apply, both from the federal level of 1557, one of the titles of the ADA, section 504 as well, as state laws, correct?


Correct. So people often ask, which law do I follow? A lot of times you are covered by multiple laws at once, especially for medical providers. You are covered by the ACA in those instances where you are accepting federal insurance and providing services covered by HHS. You are also covered by the ADA, depending on how you are set up, especially again if you are accepting insurance from federal and state dollars, if you are a private, if you are open to the public, so title II and 3 could apply as well as state laws, so in Illinois, we have state laws that are even more strict than the ADA and the Rehab Act in terms of what you are required to provide.

You might be covered by multiple laws, which one do you use as guidance for what you are required to provide, you use the one that's actually most strict that has the most provisions for the client. In Illinois, for example, we would, especially in Chicago, we would follow our local and state laws as the primary, and then also acknowledging that we are still covered by the ADA and the Rehab Act and the ACA.

Peter Berg

Shannon, real quick from the consumer side for the patient or the individual that is deaf or hard-of-hearing, that provides opportunities, other than let's say the ADA, or 1557 to file complaints or exercise their rights, right?



Peter Berg

Question here for you, Shannon. The individual wanted some clarification that there is oftentimes confusion when, for instance, the patient is not deaf but there is a companion, a family member or friend who is deaf and what are the obligations in a medical setting, for instance, in that situation. So what are the obligations of the healthcare provider to communicate with the family member or friend who is deaf or hard-of-hearing?


Sure. These requirements under the ADA, Rehab Act, ACA, they do extend to companions. There is multiple reasons for that. One good example is that often within family networks, the person who is the patient who is the direct patient is hearing, but they may be getting quite a bit of assistance from their family members in terms of care giving at home, just even knowing what is going on with my own family members, medically, they are all included in that process. There is a deaf person who is a friend of the hearing person but is accommodating them to their medical appointment, these provisions extend to them. We are required to provide accommodations to those companions.

Peter Berg

From the perspective of equal access, right, Shannon, the healthcare providers, even businesses in general communicate with the family or friends of the actual client, so that is going to extend, obviously, to the companions of families or family members who are deaf or hard-of-hearing.



Peter Berg

Another question that came in early on in this touched on some of the legal requirements, but the question is, who gets to decide, sorry, who gets to decide what effective communication is, the doctor, the patient, whose perspective trumps?


The patient or the client, the person who is consuming those services, usually is going to be the person who is going to be able to say whether they understood or not, did they understand the information. If they did not understand the information, then the accommodations was a problem. In some instances the accommodation itself is going to be the problem. Sometimes you have a sign language interpreter who is not a good match for the content. Maybe the sign language interpreter is great when they are interpreting theater but don't have medical terminology or legal, they don't know legalese. In those instances, they may not be qualified for that job. The deaf person is not able to effectively communicate through that interpreter. So again, check in with the deaf person, and if you are getting the impression that maybe this deaf person is not understanding everything, again, ask them to repeat back to you what they understood, so that you know, did they understand or not, was the accommodation effective. In some cases you might have a client who the interpreter or the captioner or whoever the accommodations provider seems to be effective, or maybe you even escalated this to, we hired a sign language interpreter, the interpreter said we hired a deaf interpreter, this time we hired both and the client is still not understanding effectively. In those cases, it might be that that deaf person should have an advocate, do they have a social worker, whoever helps them out, do they have family members, and is that something that they want. If you can rely on an advocate, then great. If not, you have at least tried to do your due diligence by hiring a deaf interpreter as well, and maybe it's, it behooves you to note in your own documentation, we hired the deaf interpreter, we hired the sign language interpreter, patient still seemed confused. I'm not sure how you document that with hearing people. But whatever you might do with a hearing person, who might seem confused on communication, you might want to take those same practices, take the same steps with a deaf person as well.

Peter Berg

Shannon, someone asked what does CDI stand for?


CDI is certified deaf interpreter. Depending on your state requirements, your state requirements might require that a deaf interpreter have certification with some kind of licensure, credentialing. I think that in states like New York and Florida they are still working to get an interpreter licensure requirement on the books. In states like Illinois, and I believe in Nevada, quite a few states do have interpreter licensure requirements. But other states don't. So it's certified deaf interpreter is what CDI stands for. Sometimes you see it written as DI which means deaf interpreter. Your needs and requirements depends on your state statutes.

Peter Berg

Great. A question, Shannon that we get oftentimes, we will hear from the healthcare provider, I had a request for a interpreter, I had a request for this, what should I do. Can you talk about, you know, from a healthcare perspective, healthcare provider's perspective why it's appropriate and necessary to have a dialogue or communication with the patient before the patient shows up regarding the request?


Again, in terms of what the deaf patient needs, do they need a sign language interpreter, are they DeafBlind or deaf low vision, do they need a DeafBlind interpreter or tactile interpreter, an interpreter who does that kind of work, do they need an interpreter who knows specialized language practices, and vocabulary, so maybe they need a interpreter who specializes in medical vocabulary. They might also need and we are getting kind of into the weeds of language here, but they might need a see sign language interpreter, or a PSE, Pidgin Sign Language interpreter or might need someone who does strict, only ASL. These are different systems within the sign language interpreting community that community members will know what this means. They will recognize it. If they do specify that with you, when you talk to the agency, you have to say they have requested a sign language interpreter who knows see sign, or signed English, and go from there. It does get slightly nuanced, depending on who that person is, and that is why you want to communicate with the client before the date of service, so that on that date of service, things can go as smoothly as possible and you don't have to interrupt the whole situation, tell somebody wait a minute, we have to reschedule, we have to start from scratch on accommodations, etcetera.

Peter Berg

Thank you very much, Shannon. We unfortunately are at the bottom of the hour. If you didn't have an opportunity to get your question answered, please reach out to us, reach out to your regional ADA center again. There is an ADA-.org to reach your ADA center. Our July session will be an ADA anniversary update. We will have Andrew Imparato joining us for that section on July 16. You can register for the session much find the information about it by visiting ADA-audio.org. Today's session is being recorded, has been recorded. And we will get an edited transcript to post it to the website in approximately three weeks. If you have questions about the ADA audio conference program, you can give us a call at 877-232-1990. I thank our speaker today, Shannon Moutinho, for all of her time with us for the past 90 minutes, as well as her time preparing today's session, and as always, thank you to all of you for joining us. Please encourage you to complete the session evaluation that helps us identify topics and areas of interest that you want to hear us present as part of the ADA audio conference series. Thank you all for joining us today. We look forward to you joining us in July. Thanks and take care. Good day, everyone.


Ladies and gentlemen, thank you for participating in today's conference. This does conclude the program. You may all disconnect. Everyone have a great day.