Access Technologies, Inc. iCanConnect - Oregon OVERVIEW Access Technologies, Inc. (ATI) has been selected by the Federal Communication Commission (FCC) to administer the National Deaf Blind Equipment Distribution Program (NDBEDP). The NDBEDP distributes equipment to low-income individuals who are deaf-blind (have combined hearing and vision loss) to enable access to telephone, advanced communications and information services. The support was mandated by the Twenty-First Century Communications and Video Accessibility Act (CVAA). For more informatin about the NDBEDP, please visit http://accesstechnologiesinc.org/ or http://www.fcc.gov/ndbedp. WHO IS ELIGIBLE TO RECEIVE EQUIPMENT? Applicant must meet the following criteria to be eligible to participate in the NDBEDP: Financial Eligibility: Applicant must meet income eligibility requirements that do not exceed 400 percent of the Federal Poverty Guidelines (FPG). NDBEDP applicants are required to provide proof of income. If you are enrolled in a federal subsidy program with an income threshold that does not exceed 400% of the Federal Poverty Guideline, you meet the income eligibility for the NDBED Program. If not, please refer to these guidelines: 2017 Federal Poverty Guidelines The first number in the list below is the Number of Persons in Family or Household and the second number is the 400% FPG level for individuals residing everywhere except in Alaska and Hawaii 1 - $48,240 2 - $64,960 3 - $81,680 4 - $98,400 5 - $115,120 6 - $131,840 7 - $148,560 8 – $165,280 For each additional person, add $16,720 Source: U.S Department of Health and Human Services For purposes of determing income elibibility for teh NDBEDP, the FCC defines "income" and "household" as follows: “Income” is all income actually received by all members of a household. This includes salary before deductions for taxes, public assistance benefits, social security payments, pensions, unemployment compensation, veteran's benefits, inheritances, alimony, child support payments, worker's compensation benefits, gifts, lottery winnings, and the like. The only exceptions are student financial aid, military housing and cost-of-living allowances, irregular income from occasional small jobs such as baby-sitting or lawn mowing, and the like. A “household” is any individual or group of individuals who are living together at the same address as one economic unit. A household may include related and unrelated persons. An “economic unit” consists of all adult individuals contributing to and sharing in the income and expenses of a household. An adult is any person eighteen years or older. If an adult has no or minimal income, and lives with someone who provides financial support to him/her, both people shall be considered part of the same household. Children under the age of eighteen living with their parents or guardians are considered to be part of the same household as their parents or guardians. See Section 2 for the family/household income information that must be provided with this application. Medical Eligibility: Applicants must meet the Helen Keller National Center (HKNC) definition of Deaf-Blind which states an individual is deaf-blind when they have: 1. a central visual acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both these conditions; and 2. a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and 3. for whom the combination of impairments described in clauses (1) and (2) cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation. Program Model For the purpose of the Pilot Program, Oregon will establish a permanent equipment loan program. During this time the title of the equipment will remain with Access Technologies, Inc. This will allow for flexibilty in the sense that as AT changes, or as a client's vision or hearing changes, individuals will be able to upgrade their AT to accommodate these changes as necessary. The technologies which are traded-in will be placed in a Device Lending Library. At the conclusion of the pilot program, Oregon will adopt a policy that allows ownership of the AT to transfer to the consumer after five years of using the equipment. Who can attest to a person’s disability eligibility? A practicing professional who has direct knowledge of the person's vision and hearing loss, such as: Audiologist Community-based service provider Educator Hearing professional Medical/health professional School for the deaf and/or blind Specialist in Deaf-Blindness Vision professional Vocational rehabilitation counselor Such professionals may also include, in the attestation, information about the individual’s functional abilities to use telecommunications, Internet access, and advanced communications services in various settings. Existing documentation that a person is deaf-blind, such as an individualized education program (IEP), or a statement from a public or private agency, such as a Social Security determination letter, may serve as verification of disability. If you disagree with the professional’s disability decision, please contact Access Technologies, Inc. 503-361-1201, or 1-800-677-7512 info@accesstechnologiesinc.org See Section 5 for the disability attestation information that must be provided with this application. Confidentiality policy ATI and iCanConnect are committed to ensuring that your privacy is protected. Information provided on this application form will only be used to determine eligibility for iCanConnect products and services. ATI and iCanConnect will not sell, distribute or lease your personal information to third parties unless you give permission, or if the iCanConnect program is required by law to do so. ATI and iCanConnect are committed to ensuring that personal information is secure. In order to prevent unauthorized access or disclosure, suitable physical, electronic and managerial procedures are in place to safeguard and secure the information Access to Telephone or Internet Services: NDBEDP equipment applicants will need to demonstrate that they have access to the telephone, Internet or wireless services that the equipment is designed to use and make accessible. Do you need help filling out the application? If you are unable to fill out the application yourself, you may ask another person to fill it out for you. Some people to ask for help might be (but is not limited to): a family member, friend, caregiver, guardian, case manager, doctor, audiologist, or another professional. The person who is filling out the application must enter the information of the person who is applying for the equipment. Instructions for the application are written in first-person: “You” means the person who is applying for telecommunication equipment. Please print or type clearly. Please fill in all fields. Have you participated in iCanConnect (the National Deaf-Blind Equipment Distribution Program) before? please note yes or no. If Yes, what state/states did you participate in iCanConnect? (list all) Did you previously receive equipment through iCanConnect in another state? If yes, what state/states di you receive equipment through iCanConnect? (list all) APPLICATION SECTION 1 of 5 Applicant's Personal Data 1.Name Last name: First name: Middle initial: 2.Gender: Please type an "x" after your selection on the next line to indicate your answer. Male Female 3.Home address: City State Zip Code 4.Mailing address (if different): City State Zip Code 5.Community/Facility name (i.e., nursing home, apartment complex) If not applicable, leave blank. 6.County: Please type the name of the County you live in. 7.Home telephone number. Please type your home telephone number, inlcuding area code on the next line. Is this number a Voice number? Is this number a VP number? Is this number a TTY? Is this number a Fax 8. Message telephone number. Please type your message telephone number, inlcuding area code on the next line. Is this number a Voice number? Is this number a VP number? Is this number a TTY? Is this number a Fax? 9. E-mail address. Please type your email address on the next line. 10. What is the best times to contact you? 11. Is your preferred method of contact by telephone? Is your preferred method of contact by your alternate telephone? Is your preferred method of contact by email? 12. Social Security Number (optional) 13. Date of Birth (MM/DD/YYYY) APPLICATION SECTION 2 of 5 Financial Income 14. Financial information: If you are enrolled in a federal subsidy program with an income threshold that does not exceed 400% of the Federal Poverty Guideline, you meet the income eligibility for the NDBED Program. Please attach a proof of enrollment. OR please provide your Family size: (parents in the household and any dependent children, including the applicant) Please provide your Monthly Gross Income: $ and please provide your Estimated Annual Gross Income:$ Attach proof of income. (paystub, tax return, SSI, SSDI, etc.) APPLICATION SECTION 3 of 5 Program Goals: What are your telecommunication goals through participation in the NDBEDP? APPLICATION SECTION 4 of 5: Client Signature: 1. I certify that all information provided on this application including informaiton about my disability and income, is true, complete and accurate to the best of my knowledge. I authorize program representatives to verify the information provided. 2. I permit information about me to be shared with my state's current and successor program managers and representatives for the administration of the program and for the delivery of equipment and services to me. I also permit information about me to be reported to the Federal Communication Commission for teh administration, operation, and oversight of the program. 3. If I am accepted into the program, I agree to use program services soley for the purposes intended. I understand that I may not sell, give, or lend to another person any equipment provided to me by the program. 4. If I provide any false records or fail to comply with these of other requirements or conditions of the program, program officals may end services to me immediately. Also, if I violate these or other requirements or conditions of the program on purpose, program officals may take legal action against me. 5. I certify that I have read, understand, and accept these conditions to participate in iCanConnect (the National Deaf-Blind Equipment Distribution Program). 1. Signature Date 2. What is the name of person completing application (if other than applicant) What is the relationship of person completing application (if other than applicant) 2a. Please type the telephone number inlcuding area code,of person completing the application (if other than applicant) on the next line. Is this telephone number a Voice, VP, TTY or Fax? 2b. Please type the email address of person completing the application (if other than applicant). 3. Pleaes type a name of alternate contact person (for applicant) What is the relationship of alternate contact person (for applicant) 3a. Please type the telephone number, inlcuding area code, of alternate contact person, on the next line. Is this telephone number a Voice, VP, TTY or Fax? 3b. Please type the email address of alternate contact person Application Section 5 of 5. Disability Verification: This section is to be completed by a medical or health professional; hearing, speech or vision specialist; representative of a state agency, or a representative of education. Vision Status: 1. Does the applicant have a visual acuity of 20/200 or less? Please type an "x" after your selection on the next line to indicate your answer. Yes No 2. Does the applicant have a field defect of 20 degrees or less? Please type an "x" after your selection on the next line to indicate your answer. Yes No 3. Do you have a reasonable expectation that this applicant will progressively reach a visual acuity of 20/200 or a field defect of 20 degrees or less? Please type an "x" after your selection on the next line to indicate your answer. Yes No Hearing Status: 1. Does this applicant have a chronic hearing impairment so severe that most speech is not understood with optimum amplification? Please type an "x" after your selection on the next line to indicate your answer. Yes No 2. Do you have a reasonable expectation that this applicant’s hearing will progress to the point that most speech is not understood with optimum amplification? Please type an "x" after your selection on the next line to indicate your answer. Yes No Independence Status: 1. Does the combination of the vision and hearing loss cause the applicant difficulty in attaining independence in daily living activities, achieving psychosocial adjustment, or obtaining a vocation? Please type an "x" after your selection on the next line to indicate your answer. Yes No Disability Verification provided by: Signature of Professional Date Printed Name and Title of Professional Professional's Mailing address Professional's E-mail address Professional's Telephone number (include area code) Is this telephone number a Voice, VP, or TTY Mail completed application to: Access Technologies, Inc. ATTN: NDBEDP 2225 Lancaster Drive NE Salem, OR 97305 This information is available in alternate format upon request.