Providing Information in Alternative Formats

June Isaacson Kailes MSW, Associate Director
Christie Mac Donald MPP, Senior Policy Analyst
Center for Disabilities Issues and the Health Professions
Western University of Health Sciences
309 E. Second Street, Pomona, CA 91766
Voice-909.469.5213/TTY-909.469.5520, Fax 909.469.5503,

Contents of this briefing


This brief will assist you in providing alternative formats. It reviews communication needs of people with visual, hearing, learning, and cognitive disabilities; and explains how you plan, produce, and deliver alternate formatted material. This brief also contains sources (vendors) for the production of alternative formats

This guide concentrates on those formats that complement conventional print and video products. Although it provides suggestions, the guide is not meant to be the definitive word on alternative formats. Future changes in technology, the communication needs of people with and without disabilities, and societal trends will continue to re-shape the area of communication access.

Communication Access in Health Care

This brief will assist you in providing alternative formats. It reviews communication needs of people with visual, hearing, learning, and cognitive disabilities; and explains how you plan, produce, and deliver alternate formatted material. This brief also contains sources (vendors) for the production of alternative formats

This guide concentrates on those formats that complement conventional print and video products. Although it provides suggestions, the guide is not meant to be the definitive word on alternative formats. Future changes in technology, the communication needs of people with and without disabilities, and societal trends will continue to re-shape the area of communication access.
A. Communication Access in Health Care

The major pieces of federal legislation governing equal access to health care services for individuals with disabilities are the Rehabilitation Act (Rehab Act) and the Americans with Disabilities Act (ADA). These laws constitute a national mandate prohibiting discrimination based on disability in the provision of goods and services available to the public.

Section 504 of the Rehab Act prohibits any organization that receives federal financial assistance from denying individuals with disabilities equal access to the services it offers. For example, hospitals, clinics, and other health care agencies that accept Medicaid, Medicare, or any other form of federal funding must comply with the Rehab Act. Section 504 states, “No otherwise qualified individual with a disability . . . shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” 1

ADA’s Title II extends the Rehab Act’s requirements to all state and local government activities. All health care providers who offer health care services, either directly or through contractual arrangements, to Medicare or Medicaid beneficiaries must comply with the Rehab Act because Medicare and Medicaid funding is considered federal financial assistance. 2 If the provider serves just one Medicare or Medicaid beneficiary, that provider’s entire operations must comply with the Rehab Act. 3 Medicare and Medicaid managed care plans must provide programmatic access to all its enrollees with disabilities.

ADA’s Title III states: “No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges advantages, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation.” All health care providers, including hospitals, nursing homes, psychiatric and psychological services, private physicians’ offices, diagnostic centers, physical therapy centers, and health clinics, are places of public accommodations and therefore must comply with Title III.

Managed care plans are vicariously liable for their member providers’ discriminatory actions because of the contractual relationship between the parties. 4 Managed care plan shares with its contracted organizations the responsibility for ensuring that these organizations provide accessible services to the greatest extent possible. The law calls this responsibility “vicarious liability.” In others words, managed care plans share their contractual Rehab Act and ADA responsibilities through the contract relationships. Different models of managed care plans have different levels of vicarious liability based on the interaction with and degree of control over the health care providers, medical groups, hospitals, and other agencies with whom they contract.

The goal is to provide effective and accurately understood information, so people with disabilities receive health and preventive care that is equally effective as that provided to others.

The responsibility to offer alternative formats is covered under the ADA’s effective communication mandate. This requires state and local government and health care providers to communicate effectively with individuals who are deaf, hard-of-hearing, or have a speech, vision or learning disability. Communication access involves providing content in methods that are understandable and usable by people with: reduced or no ability to: speak, see, hear and limitations in learning and understanding.

Who needs materials in alternative formats?

You may need to use alternative formatted materials for people with reduced or no ability to; see or hear; or, for people with limitations in learning and understanding.

Ensuring effective communication in health care is more than a legal requirement.
When effective communication doesn’t happen, the quality, standards and actual care received by people with disabilities may be in question. Providing all patients with well understood information enables people to use medical information in a safe and effective manner, and can reduce medical error by both professionals and patients.

Alternative Formats

Example of the types of health-related information which may need to be provided in alternative formats include:

  • Explanation of Member’s benefit rights, informed consent or permission for treatment;
  • Newsletters;
  • Explanation of activities, procedures, tests, and treatments;
  • Provision of mental health evaluations, individual, group and family therapy, counseling, and other therapeutic activities, including grief counseling and crisis intervention;
  • Provision of health educational services and presentations;
  • Explanation of prescribed medications (dosage, instructions for how and when the medication is to be taken, side effects, food and drug interactions);
  • Explanation of follow-up care, treatment, therapies, test results or other recovery care direction;
  • Descriptions of the types of programs and/or services provided in the form of brochures, pamphlets and application materials;
  • Marketing materials;
  • Explanations of Coverage, Member Guide, Provider Directory, Member’s rights;
  • Letters: Notice of Action, Grievance acknowledgements and resolution;
  • Admissions, discharge and/or orientation; determination and explanation of patient’s diagnosis or prognosis;
  • Member newsletters; and
  • Preventative health reminders.

Alternative Formats Likely to be Requested

Alternative formats likely to be requested include, but are not limited to:

  • Audio-formats: Text recorded on tape, disks, and CDs.
  • Braille
  • Descriptive narration: Video description (also called audio description) makes television and other visual media accessible to people who are blind or visually impaired. Narrative descriptions of a program’s key visual elements such as actions, graphics and scene changes are recorded and carefully blended into natural pauses in the program soundtrack, creating an additional mixed audio track that is broadcast or shown simultaneously with the program.
  • Large print: Text produced in Arial or other sans Serif Font. Font depends on user needs, consult with the individual.
  • Captioned films and videos: The spoken word appears in written text on the bottom of the screen as in subtitles. “Open” captions can be seen by everyone while “closed” captions are visible only when activated backup the viewer.
  • Electronic text/disk/CD-ROM: Text saved onto a computer disk or CD-ROM. The user gains access to information through a computer connected to a braille printer, voice output, print monitor or any other system providing access.
  • Signed films and videos: The spoken word is transferred to sign language on the screen.

Responsibilities and Contracting

Who is responsible for producing materials in alternative formats?

A public entity cannot avoid its responsibilities by contracting with private agencies that have discriminatory policies or practices.

The ADA requires contracts to state specifically who has ADA responsibility. This language should be in the contract. Consult with your legal advisor on ADA contract language. Here is one example of sample contract language.

“When services involve presentations and workshops, client will conduct these activities in compliance with the American with Disabilities Act (ADA) and will insure that as needed: the meeting site has both physical and communication access for people with disabilities; materials are available in alternative formats (braille, disk, large print, audio format); interpreters and assistive listening systems are available, and televisions, when used, are equipped with decoders for displaying captioning on video tapes.” 5

Notification of availability of alternative formats

Print materials distributed to the public should contain a statement that lets people know that alternative formats are available upon request. The notification sentence should be in large print (sans serif font, such as Arial font) so that people who need this alternative format (large print) would be able to read that it is available.

For example:

This material is available in alternative formats upon request. Please contact [name, email address and telephone number, including a TTY number], [insert number of days (i.e. 7-10 days)] before the event.

Below are examples of symbols that help you promote the availability alternative formats. Use these symbols in same location where public information is displayed, such as program brochures, application forms, event flyers, public meeting or hearing notices, etc. Symbols should be 18 point+. 6

Symbols you can use to indicate availability of alternative formats

Large print symbol, white text on black background
Large print version available

Braille symbol, white text on black background
Brailled version available

If an event that is likely to be of particular interest to the disability community, planners should have large print alternative available at the meeting. 7

Effective production of alternative formats


Advance planning and budgeting helps to facilitate the smooth production of alternative format. 8 Some alternative formats can be produced in-house at minimal costs e.g. large print, disks and email attachments. Other formats such as braille and audio-formats may need to be produced by a vendor. (See Alternative Format Vendors)

  • Keep an electronic version of materials produced
    Keep text versions of material produced for future use. This allows you to make future changes to a publication, and facilitate conversion to alternative formats, easily and quickly. 9
  • Develop a written communication access policy
    Establish a written communications policy with procedures detailing where and how staff can obtain alternative formats when requested. Procedures should include:

    • Where the public should make a request and the number of days of notice that is required,
    • Where staff go to fill requests,
    • Types of alternative formats available,
    • Staff or contracted service, and
    • Turn-around (production) time.
      For example:
      “If material is needed in an alternative formats, contact XXXX at XXXXX or (TTY) XXXX Monday – Friday, 9:00 a.m. to 5:00 p.m.

Providing Alternative Formats

The requested alternative format should be provided in a timely fashion.
Depending on the format requested, it may take a few minutes, a day, a week, or more to provide the alternative format. Making a large print version or putting the document on a disk or CD-ROM may be easily and quickly accomplished. Providing a brailled or audio-format may take up to a week or longer, depending upon the length and complexity of the document. 10

If someone requests a specific alternative format, you may offer other alternatives. For example, if people request information in braille, you may mention that you can also provide it on a disk or audio format. They may choose disk or may confirm the request for braille. They may not have a computer, or may prefer the usability of braille, especially when they needed to repeatedly refer to the information, such as an example of benefits publication. 11

Tips for providing information in alternative formats

Large Print
Many people with visual disabilities have some sight and can read large print. Large print material may be produced using a photocopier or a computer. When someone requests a document in large print, remember to ask if there is a preferred font style and/or font size because individual needs vary.

One person may request the document in Univers 14-point font, while another may request Arial 18-point bold font. As a default, use Arial font. The contrast and color choices you use for your printed documents may either reduce or can enhance people the visual effectiveness of the information. 12

  • Paper
    • The best contrast with the least glare is off-white or yellow paper. Shiny white paper produces glare.
    • If white paper is used, use an off-white paper.
    • The paper should not be larger than standard 8 1/2″ X 11.” 13
  • Formatting
    • Simplify formatting. Remove formatting codes that make the document more difficult to read. For example, centered text is difficult for some people to track.
    • Text should begin at the left margin.
    • Avoid the use of columns.
    • Use dot leaders linking title to page for tables of contents.
    • Use one-inch margins and use right margins that are ragged, not justified.
    • The line of text should be no longer than 6″. Anything longer than 6″ will not track well for people who use magnifiers. 14
  • Color and Contrast
    • Exaggerate lightness differences between foreground and background colors, and avoid using colors of similar lightness adjacent to one another.
    • Choose dark colors with hues, and avoid contrasting light colors.
    • Avoid contrasting hues from adjacent parts of the hue circle, especially if the colors do not contrast sharply in lightness. 15

Not all people who are blind can read braille, but for those who do, provide printed materials in Grade 2 braille. It is recommend that you save your documents in Word, or a text file; then you can e-mail the document to your braille vendor. (Sources for Production of Alternative Formats).

  • Formatting
    • When possible, provide the original material in disk format. Transcription is more efficient and less expensive when working from a disk than printed copy. There are scanning or retyping charges when the document is not supplied in electronic format. 16
  • Length and complexity
    • Prices for braille documents are estimated by the number of pages. Price increases if the document includes complex formatting (e.g. tables, and diagrams).
  • Binding
    • Binding is recommended for documents over 10 pages long. It is best to spiral bind braille publications and have a flexible cover on the back and front of long documents.
    • If a document is to be kept for reference purposes, it should have a cover to keep the dots from wearing down from the wear and tear of surface contact. Braille documents should lie flat for ease of reading. 17

Audio Formats
When recording material:

  • The reader should have a clear crisp reading voice and read at a moderate speed, or the material can be read professionally; see Sources for Production of Alternative Formats.
  • Recording should be done in a room where there is no background noise. At the beginning of the tape, identify the reader, i.e.: “This document is being read by Darrell Jones.”
  • On each side of an audio tape, identify the document and the page number where the reader is continuing, i.e.: “tape 2, side 1, Guide to Barrier Free Meetings, continuing on page 75.” 18

CD-ROM, Computer Disk or Email

  • A growing number of people prefer to receive materials on disks or by e-mail, so they can then listen by utilizing voice output on their personal computers. They read the documents by utilizing print enlarging software or hardware. 19

PDF Documents

PDF files are the standard for sharing richly formatted documents. More than 20 million documents are available using this format on the World Wide Web, with more than two million on government web sites. 20 Individuals with vision disabilities who cannot access standard print documents on a computer, use screen readers and computer braille interfaces to access the information.

Portable Document Format (PDF) software such as Acrobat,™ version 7.0 has made significant improvements over prior versions in removing accessibility barriers. 21

The problem remains, that users must have both, a current version of their screen reader and Adobe 7.0 22 to fully utilize Adobe’s current access features. Because this is often not the case and to ensure the widest possible usage, PDF documents posted on web sites should also be “directly linked to a duplicate file containing the same information in an accessible format.” e.g. html or Word. If this is not possible, then a direct link to a PDF reader (plug-in) that conforms to the software requirements of Section 508 of the Rehabilitation Act must be available e.g. Adobe 7.0. 23

Sources for Production of Alternative Formats

Inclusion in this resource list does not constitute endorsement by the Center for Disabilities Issues and the Health Professions, nor does omission imply non-endorsement. The goal is to provide you with some resources you can evaluate based on your needs. The vendors listed can convert materials into the following formats:

      1. Braille
      2. Large Print
    • Audio-Formats
      1. Audio-tape
      2. CD’s
      3. Disks
      1. Descriptive Narration and Captioning


Agency Address Phone/Fax Email/Web-site Alternate Formats Produced
Access Ingenuity 3635 Montgomery Drive, Santa Rosa, CA 95405 (877) 579-4380
(707) 579-4273

Access-USA 242 James Street (mail via: PO Drawer 160),
Clayton NY 13624
800-263-2750 or
American Foundation for the Blind 11 Penn Plaza, Suite 300
New York, NY 10001
(212) 502-7600
(800) 392-3305
(212) 502-7777.
American Printing House for the Blind 1839 Frankfort Avenue
P.O. Box 6085
Louisville, Kentucky 40206-0085
800-223-1839 (U.S. and Canada)
FAX: 502-899-2274
Associated Services for the Blind 919 Walnut Street,
Philadelphia, PA 19107
(215) 627-0600
(215) 922-0692
Braille Institute 741 N. Vermont Avenue

Los Angeles, CA 90029-3594

800.BRAILLE (272.4553) Email:
Braille Plus, Inc. 3276 Commercial Street SE

Salem, Oregon 97302


(503) 391-9359



Lighthouse for the Blind/Rose Resnick Center 214 Van Ness Avenue

San Francisco, CA 94013

(415) 431-1481
(415) 431-4572
(415) 763-7568
MSMT Braille Center 11 With. Barham Avenue

Santa Rosa, CA 95407

707.579.1115 Web:
1,2 (no audio)
National Braille Press 88 St. Stephen Street
Boston, MA 02115
1,2 (no audio)
National Federation for the Blind of California 175 East Olive Avenue, Suite 308
Burbank, CA 91502
(818) 558-6524
(818) 729-7930
1,2 (no audio)
The Media Access Group at WGBH Media Access
300 E. Magnolia Blvd., 2nd Floor
Burbank, CA 91502
Quik-Scrybe 1723 Sumac Street
Longmont, CO 80501
(303) 485-6895
(888) 820-7845
(303) 772-7340
1 (Braille only)
Recording for the Blind and Dyslexic 20 Rosel Road
Princeton, New Jersey 08540
800.803.7201 Email:
Audio Only 3,4,5
WRS Motion Picture and Video Laboratory 1000 Napor Boulevard
Pittsburgh, PA 15205
(412) 937-7700
(412) 922-1020
Audio Only 3,4,5,6

Additional Communication Resources

Arditi, Aries, “Effective Color Contrast Designing for People with Partial Sight and Color Deficiencies.” Lighthouse International, 1999.

This covers principles of designing effective color contrast for people with partial sight or congenital color disability.

Arditi, Aries, “Making Text Legible: Designing for People with Partial Sight,”
Lighthouse International. 1999.

This covers maximizing legibility for people with partial sight.

Kailes, J., Accessibility Guidelines for Speakers, March 1993, Revised July 2000,

A concise guide offering important tips in assuring access to the widest possible audience. Includes how to: make visual aids accessible through oral narratives and format; work with sign language interpreters; make soundtracks accessible through captioning; work with assistive listening systems; convert handout materials to alternative formats (braille, large print, disk, audio cassette); record material on audio cassette; and locate braille transcription, captioning, recording and duplicating services.

Kailes and Jones, “A Guide to Planning Accessible Meetings.” ILRU,1993.

The fundamental issues to consider when arranging a meeting that allows for attendance and participation of people with disabilities, divided into two major categories: (1.) the physical accessibility issues related to hotel, meeting facilities and the location of the meeting; and (2.) the accessibility of information that is presented and disseminated at the meeting.

North Carolina Office on Disability and Health with Woodward Communications
Barriers: Tips and Strategies to Promote Accessible Communication
. 2002.

Addresses the basics in communicating with people with disabilities.


  1. 29 U.S.C. § 794 (1994)
  2. Title II applies to all public entities, defined
    as “any state or local government. 42 U.S.C. §12131 (2002). Section
    504 applies to any entity that receives federal funding. 29 U.S.C. §
    794. Federal financial assistance can be direct or indirect. Jacobson
    v. Delta airlines
    , Inc., 742 F.2d 1202, 1211 (9th Cir. 1984).
  3. The legislative history of the Civil Rights Restoration
    Act provided that if federal health assistance is extended to a part of
    a state health department, the entire health department would be covered
    in all of its operations. S. Rep. No. 100-64, at 16 (1987), reprinted
    1988 U.S.C.C.A.N. 18.
  4. Zamora-Quezada v. Health Texas Medical Group
    of San Antonio
    , 34 F.Supp.2d 433 (W.D. Tex. 1998)(denying defendant’s
    motion for summary judgment because of fact question as to whether the
    HMOs regulated health care decisions made by the medical group, including
    referrals and admissions, and attempted to monitor and influence physicians’
    utilization patterns.); Woolfolk v. Duncan, 872 F.Supp. 1381
    (E.D. Pa. 1995)(holding that where MCO has right and authority to interfere
    with and control a provider’s treatment of enrollees, there is a genuine
    issue of material fact as to whether MCO is vicariously liable for provider’s
    conduct under Title III of the ADA and Section 504.)
  5. Isaacson-Kailes, June. Sample ADA Contract
    Language 2005
  6. Ibid.
  7. Ibid.
  8. Ibid.
  9. Ibid.
  10. Ibid.
  11. City of Long Beach California, Department of Human
    Resources, ADA
    Requirements for Publications for the Public and City Contracts
  12. Brown, Holland, Isaacson Kailes, and Lester (2001)
    Aware: Extending your reach to People with Disabilities: III. Communication
    . Alliance for Technology Access.
  13. Ibid.
  14. Arditi, Aries, (1990) “Effective
    Color Contrast Designing for People with Partial Sight and Color Deficiencies.”

    Lighthouse International.
  15. Brown, Holland, Isaacson Kailes, and Lester, (2001)
  16. Kailes and Jones, (1993) A
    Guide to Planning Accessible Meetings
    . ILRU.
  17. Ibid.
  18. North Carolina Office on Disability and Health,
    (1990) Removing
    Barriers: Tips and Strategies to Promote Accessible Communication
    Woodward Communications
  19. Adobe
    Tackles Software Accessibility Issues
    , (2005) American Foundation
    for the Blind.
  20. Mazrui, J., (2005)AccessIssues-AccessWorld, “What’s
    in a PDF? The Challenges of the Popular Portable Document Format.”

    November 2005, Vol. 6, Number 6
  21. Jay Leventhal is Editor in Chief for AccessWorld,
    the consulting arm for the American
    Foundation for the Blind
  22. Section 508. Section

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Distribution is encouraged, and permission is granted provided that:

(1) This copyright notice and citation is attached to each copy;

Kailes, J., and Mac Donald, C., Tax Incentives For Improving Accessibility, 2004. Published and distributed by the Center for Disability Issues and the Health Profession, Western University of Health Sciences, 309 E. Second Street, Pomona, CA 91766 1854, (available at Email: Voice-909.469.5213/TTY-909.469.5520, Fax 909.469.5503,

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The California Foundation for Independent Living Centers is a statewide, non-profit trade organization made up of 25 Independent Living Centers. Through unified action, CFILC envisions civil rights for all people with disabilities. CFILC’s mission is to support independent living centers in their local communities through advocating for systems change and promoting access and integration for people with disabilities.