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Welcome to the August  2016 issue of the CommonLook Accessibility Newsletter!

This month we invite you to review your knowledge of PDF Basics and what it really means to be compliant.   On the accessibility news front CommonLook PDF Validator is reviewed by Jon Metz of the Paciello Group..

The heaalthcare industry is continually evolving, This month our Industry Spotlight focuses on healthcare and its unique challenges as it relates to document accessibility.

As always, we welcome your suggestions for upcoming topics and would like to know what you think of NetCentric’s CommonLook Accessibility Newsletter.

Use this link to share your comments or story ideas with the CommonLook Accessibility Newsletter staff.

We Hope You Enjoy!

The CommonLook Accessibility Newsletter Team



PDF  Basics:What Does Compliance Mean


We often talk about an organization or documents being “compliant” with legislation and/or specific standards. Most of us “know” what that means. This article is a refresher for those of us with years of experience and a starting point for those new to the field of PDF and/or document accessibility.

For PDF documents, being compliant with any standard or guideline, whether it be WCAG or PDF/UA means that someone who cannot decode or read the visual representation of the document can still determine the document content and the structure of that content. This is done through “tagging” the document.

No matter which standard or guidelines you use, there are some basic elements to an accessible tagged conforming PDF document.

The document itself must have a language attribute.

Although we would like to identify specific dialects and regional pronunciations when assigning the language attribute, this can create a barrier for the person using a screen reader or Text-to-Speech tool.

The choice of which synthesized voice used is a personal one. After all, someone using screen reading or Text-to-Speech tools listen to the computer for many hours a day. If a person uses a British voice with British pronunciations and the language attribute for a document says it is American English, the person who chooses or uses the British pronunciations will be forced to use an American sounding voice with American pronunciations of words. This is often disorienting  as text is not pronounced and heard in a familiar way. It can take quite a while to adapt to listening to content using pronunciations that someone is not used to hearing.

When assigning the language attribute, use plain language assignments like English, French, Spanish, Portuguese and German. Avoid using language attributes like EN-CA (Canadian English), EN-US (American English) or EN-AU (Australian English)…see how complex it can get in pronouncing words?!

If a paragraph or section is in a different language, the language attribute is changed for that specific content. This can be done for an individual tag or a <Part> or <Sect> tag.

If a word or phrase is in a different language, the <Span> tag is used to isolate the word or phrase and the language attribute is changed for the <Span> tag.

What this means to the person reading the document using either a screen reader or Text-to-Speech tool is that the content/text will be pronounced using the appropriate speech synthesizer. For example, if the document is in English and a paragraph is in Spanish, the English voice will be used until the screen reader or Text-to-Speech tool comes across the tag with the Spanish language attribute at which point a Spanish voice/pronunciation is used. Once the adaptive technology finishes that paragraph and leaves that tag, the voice/language reverts back to English, or the core language for the document.

It is the same for a word or phrase that has the <Span> tag to allow the identification of a different language. The part of the sentence that is in English will be read using an english synthesized voice, the Spanish voice will read/pronounce the Spanish word or phrase and then the English voice takes over again to continue reading the sentence.

The document must be in a logical reading order.

Adaptive technology such as screen readers or Text-to-Speech tools read the tags tree. As you move down the tags Tree, the content should flow in the order in which it is read in the document. This can be verified using the Highlight Content in the tags Tree which should be turned on by default. In some cases, like a brochure, this may not be the same order as it appears in the document. Someone reading through the document has to be able to make sense of what they are reading.

The tags must be correct for the type of content they are assigned to.

Content must have the correct tags. For example, headings must use the <Hx> tag where “x” represents a heading level. The heading levels must be sequential and cannot skip levels. Headings cannot be used for paragraphs of text. Headings are navigational elements in a PDF document.

Bookmarks in a PDF document should mirror the headings and heading levels in the document.

Some adaptive technologies are able to get a list of headings in a document to allow for quick navigation to a specific topic. For those using adaptive technology that is not able to provide a list of headings or move through headings in a PDF document, Bookmarks are an essential navigational tool. Bookmarks can be used by everyone and let the person reading the document quickly find a topic without having to go back to a table of contents (if there is one in the document).

Each paragraph must have a <P> or Paragraph tag. While a single <P>tag can include the individual lines for a paragraph, one paragraph has one <P> tag. Multiple paragraphs cannot “share” the same <P> tag.

Lists must be tagged correctly

Lists must have a parent <L> tag with the correct <LI>, <Lbl> and <LBody> tags under it.

The correct use of the list tag is important for anyone using a screen reader or Text-to-Speech tool because a list structure identifies a relationship between pieces of content. Adaptive technology can announce that a person is entering a list, how many items are in the list, each listed item and when the person is leaving the list.

Tables must be tagged correctly.

Speaking of relationships, tables must also be correctly tagged in order for adaptive technology to be able to provide information about column and row titles (also known as table headers); and how a number in a data cell is related to those column and row titles.

Consider what you would discern and decode if all you heard was “$525, cell B6.”

By correctly tagging a table and identifying table header cells, someone using adaptive technology would be able to get the following information: “2014, Jesse Doe, $525, cell B6.” By adding the year of sales and the salesperson, the number has a relationship to something other than the cell coordinates. The table header information can be supported with a caption/summary and hopefully surrounding content.

Alt Text for Images and Links

The last “basic” item is Alt Text for images and links. Images that are decorative can be put in the background so that they are ignored by adaptive technology. Alt Text is given to images that support the content of the document. Links are provided with Alt text so that when someone using a screen reader or text-to-Speech tool navigates by link they hear something like “CommonLook Global Access” rather than

Consider this barrier when it comes to links: if all links begin with http…then a person using a screen reader or Text-to-Speech tool who can get a list of links will have to listen to all of the characters in all of the links in order to find the one that they want. By adding Alt text to links, someone can press C for CommonLook Global Access and quickly move to the first item that begins with C. By repeatedly pressing the letter C, they can cycle through specific links until they find the CommonLook one. This is a much faster and less frustrating way of locating the link you want.


These are the very basic elements of a tagged accessible conforming PDF document. These are the must have’s on a list of PDF remediation techniques and elements. As we can see from the benefits to the person who is reading the PDF document, all of the basics listed here provide navigation, context and content in a way that is easy to read through.

Most screen readers and some Text-to-Speech tools have a tool that lets someone get a list of links or a list of graphics/images. This allows for more granular access to specific types of content.

As a last word, when starting with an untagged PDF document, Adobe Systems has an established hierarchy of tasks to perform, a process to go through before you add tags to a document:

  1. If the document is a scanned image of a document, perform OCR (Optical Character Recognition) which is found under Enhanced Scan in the Tools Task pane Adobe Acrobat DC.
  2. If the document is a fillable form, add the form fields which are found under the Prepare Form tools in the Tools Task Pane in Acrobat Pro DC.
  3. If the document has links, add the links to the document using the Link tools which are found in the Edit PDF tools in the Tools Task Pane in Acrobat DC. You can use the Create web addresses from URL’s to start with and then manually add any links the automated tool may have missed (such as links beginning with www instead of http).

AFTER all of these items have been asked, answered and dealt with, THEN you tag the PDF document.






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CommonLook PDF Validator Demonstration By Paciello Group 

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Jon Metz of The Paciello Group  has created a video  titled: Making sure your PDF/UA PDF is actually PDFUA w/ Jon Metz.   The recording discusses the nuances of PDF/UA Compliance and how to check documents against the standard.   During the video Jon utilizes CommonLook’s  PDF Validator to test document compliance and remediation needs. He noted CommonLook’s PDF Validator is “a more robust validation and reporting tool”.  He also adds, “what’s great about this tool, aside from the fact that it’s free is that it does a really great job of checking to make sure  that it meets the requirements for a bunch of different  standards.”

For the complete video:

Download Your Copy of CommonLook’s PDF Validator


Industry Spotlight:  Healthcare  



By now, it’s certainly no surprise that accessibility for persons with disabilities is an issue of major concern for users of information communications and technology (ICT).  Many implementers have been aware of accessibility’s particular significance in certain vertical markets such as education, financial services, and the public sector.

Health care and accessibility are innately linked. There is a natural relationship between accessibility and health issues, as a significant number of applicants and beneficiaries for health care also possess a disability as a result of their health issues. Permanent or temporary disability is frequently a symptom of illness, disease, or injury.

Because of this close relationship between health and accessibility, it should come as no surprise that the Patient Protection and Affordable Care Act (ACA) places a high level of importance on the accessibility of electronic information for persons with disabilities. In addition to the operational standards which a Qualified Health Care Providers (QHP) must meet, the ACA goes to great lengths to specify technical requirements a QHP must satisfy when it comes to providing services that are accessible to persons with disabilities, are non-discriminatory, and are available to persons with Limited English Proficiency (LEP).

As it has done in previous annual letters to Issuers in the Federally Facilitated Marketplace (FFM), the Centers for Medicare and Medicaid Services (CMS), in the Chapter entitled Consumer Support and Related Issues has a section devoted to what it calls Meaningful Access (In the 2015 Letter dated March 14, 2014 this is Chapter 6, Section 4, on page 44).

The Meaningful Access section describes the measures QHP issuers in the Federally Facilitated Marketplace (FFM) are encouraged to take to comply with the requirements that they ensure meaningful access by limited-English proficient (LEP) speakers and by individuals with disabilities.

QHP issuers must ensure access for individuals with disabilities, including through the provision of auxiliary aids and services. CMS notes that all web content or communications materials produced by the FFM and its contractors – including text, audio or video, will conform to applicable standards related to section 508 of the Rehabilitation Act and, where applicable, the Americans with Disabilities Act and section 504 of the Rehabilitation Act.  CMS expects that QHP issuers will ensure meaningful access to at least the following items which it designates as essential documents:

  • Applications (including the single streamlined application);
  • Consent, grievance, and complaint forms, and any documents requiring a signature;
  • Correspondence containing information about eligibility and participation criteria;
  • Notices pertaining to the denial, reduction, modification, or termination of services, benefits, non payment, and/or coverage;
  • A plan’s explanation of benefits or similar claim processing information;
  • QHP ratings information;
  • Rebate notices; and
  • Any other document that contains information that is critical for obtaining health insurance coverage or access to care through the QHP.

In short, any document a QHP may choose to issue electronically falls under the Meaningful Access requirement.

The annual CMS letter isn’t simply a friendly reminder of a QHP’s obligation to provide meaningful access. The Accessibility standards for a QHP are codified in Title 45 of the Code of Federal Regulations (CFR) – “Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act” in Chapter 155 Sections 205 and 230, and in Chapter 156 Section 250.

Furthermore, QHP issuers are reminded that meaningful access requirements spelled out in 45 CFR 155.205(c), 155.230(b), and 156.250, as well as the discrimination prohibitions at 45 CFR 156.200(e), are independent of other obligations QHPs may have.  For example, QHP issuers that receive federal financial assistance are subject to Title VI of the Civil Rights Act of 1964, section 504 of the Rehabilitation Act of 1973, and section 1557 of the ACA (the civil rights provision of the Affordable Care Act). As a result, QHPs have separate responsibilities under the law not to discriminate on the basis of race, color, national origin, sex, age and disability, in providing access to their services.

While all this sounds intimidating, there’s no need to be overwhelmed by all of these rules, references, guidelines, citations, and acronyms.

NetCentric Technologies and its CommonLook brand of document accessibility products and services make it easy to produce content that complies with all of the accessibility requirements of the Affordable Care Act. Not only does NetCentric have the technical expertise for making documents compliant with the various accessibility regulations, we have extensive experience providing these services to numerous customers in the health care industry including regulatory agencies, health care deliverers, pharmaceutical manufacturers, and health insurance providers. Our CommonLook PDF Global Access has successfully been applied to every conceivable type of document, notice, and form with the result being an assurance that the content complies fully with all of the document accessibility requirements established by the government for compliance with the Patient Protection and Affordable Care Act.