Accessible Interfaces for Medical Instrumentation:
Draft Guidelines and Future Directions

	
Name (first, middle (initial), last): 	
Company or affiliation: 	
Address: 	
	
City: 	 State: 	 Zip: 	
Phone: 	  Email: 		
First name or nickname as it should appear on badge: 	
Accessibility requirements: 			
			
Employment Profile:
I work for: (check one)
	Hospital or medical clinic
	University or other educational institution
	Government agency
	Manufacturer
	Vendor or independent service organization
	Consultancy
	Other 			
The profession(s) I am associated with: (check one or more)
	Physician
	Dentist, optometrist, or other medical specialist 
	Nurse, practical nurse, nurse practitioner, or nurse aide
	Physical, occupational, speech-language or other therapist
	Biomedical or clinical engineer
	Human factors/ergonomics specialist
	Healthcare administrator
	Manufacturer
	Researcher 
	Educator
	Other 			

Name: 			
Breakout Session Preference 
Please mark your first, second and third choices as 1, 2, and 3 in the boxes below. We will try to place you into your first or second choice.
Medical Device Design Guidelines:
	A.	Positioning/Orienting of Patient to Device
	B.	Interfaces for Monitoring Devices (esp. for practitioners)
	C.	Interfaces for Home Healthcare Devices
Emerging trends and technologies for:
	D.	Interfaces for Patients with Disabilities
	E.	Interfaces for Aging and Disabled Providers

Meeting Accommodation Requests – Check all that apply, if any:
	Interpreter – specify type: 			
	Materials in alternate format – specify type: 	
				
				
	Captioning with screen display
	Hearing or listening devices – specify type: 	
				
	I am a wheelchair/scooter user
	Other: 			
				

Registration Fee	
Includes all workshop materials: 			$200
Payment Method
All conference registrations must be prepaid by check or money order, made out to “CDIHP/RERC-AMI.” Please mail your payment with this form in the enclosed addressed, postage-paid envelope.