Access Technologies, Inc. iCanConnect - Oregon APPLICATION SECTION 1 of 6 Instructions and Guidelines 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 of 2010 (CVAA). For more information 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 financial and medical criteria to be eligible to participate in the NDBEDP, and applicants must provide verification of their status as low-income and deaf-blind. Financial Eligibility: To be eligible, your family/household income must be below 400% of the Federal Poverty Guidelines, as shown in the following table. For purposes of determining income eligibility for the 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. 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 See Section 3 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. In general, the individual must have a certain vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working). Specifically, the FCC’s NDBEDP rule 64.6203(c) states that an individual who is “deaf-blind” is: (1) Any individual: i. Who has 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; ii. Who has 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 iii. for whom the combination of impairments described in . . . (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation. (2) An individual’s functional abilities with respect to using Telecommunications service, Internet access service, and advanced communication services, including interexchange services and advanced telecommunications and information services in various environments shall be considered when determining whether the individual is deaf-blind under (ii) and (iii) of this section. (3) The definition also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives. 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 Speech pathologist 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 Social Security determination letter, may serve as verification of disability. If you disagree with the professional’s disability decision, please contact Access Technologies, Inc. by phone at 503-361-1201, or 1-800-677-7512 by email at info@accesstechnologiesinc.org See Section 6 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 ATI and iCanConnect collects. Program Model iCanConnect-Oregon is a permanent equipment loan program. During this time the title of the equipment remains with Access Technologies, Inc. This allows for flexibility 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. Technologies that are traded-in are distributed to another Program consumer, or placed in the Device Lending Library, for use during assessments or while a consumer’s equipment is being repaired. Additionally, with the onset of the permanent rules, iCanConnect-Oregon has adopted a policy that allows ownership of the AT to transfer to the consumer after five years of using the equipment. 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. The person who is filling out the application must enter the information of the person who is applying for the equipment. APPLICATION SECTION 2 of 6 Applicant's Personal Data 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. 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.Social Security Number (optional) 4. Date of Birth (MM/DD/YYYY) 5.Home address: City State Zip Code 6.Mailing address (if different): City State Zip Code 7.Community/Facility name (i.e., nursing home, apartment complex) If not applicable, leave blank. 8. County: Please type the name of the County you live in. 9. 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 10. 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? 11.E-mail address. Please type your email address on the next line. 12.What is the best times to contact you? 13. 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? 14. State in which you are a permanet resident. 15. 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) 16. Did you previously receive equipment through iCanConnect in another state? If yes, what state/states did you receive equipment through iCanConnect? (list all) 17.Please note your language preference (ASL, Close Vision ASL/PSE, Tactile ASL/PSE, Pidgin Signed English, Signed English, English Spoken, Spanish Spoken, No Formal Language, or Other. If you select other, please describe. 18. Which format do you prefer for written coorespondience (Braille, Email, Large Print, Standard Print, Other) If you select other, please describe. If you are under age 18, your parent or legal guardian must sign the application. APPLICATION SECTION 3 of 6 Financial Income Income eligibility To confirm your income eligibility, please mail or fax documentation that proves you are currently enrolled in a federal program with an income eligibility requirement that does not exceed 400% of the Federal Poverty Guidelines, such as the following: Medicaid, Supplemental Security Income (SSI), Federal public housing assistance or Section 8, Food Stamps or Supplement Nutrition Assistance Program (SNAP), Veterans and Survivors Pension Benefit, etc. If none of the above applies, mail or fax a copy of last year’s Federal IRS 1040 tax form(s) filed by you and members of your family/household, or send other evidence of your total family/household income, such as recent Social Security Administration retirement benefit statement(s) or other pension benefit statement(s). Include a signed statement that attests that what you are submitting represents your total family/household income. Additionally, if you are not enrolled in a federal subsidy program, please provide the following: Family size:(parents in the household and any dependent children, including the applicant) Monthly Gross Income: $ Estimated Annual Gross Income: $ Please note, Income eligibility is valid for ONE year. APPLICATION SECTION 4 of 6 Client Signature: 1. I certify that all information provided on this application, including information 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 Communications Commission for the administration, operation, and oversight of the program. 3. If I am accepted into the program, I agree to use program services solely 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 or other requirements or conditions of the program, program officials may end services to me immediately. Also, if I violate these or other requirements or conditions of the program on purpose, program officials 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). Print name of applicant or parent/guardian if applicant is under age 18: Signature of applicant or parent/guardian if applicant is under age 18: APPLICATION SECTION 5 of 6 Program Goals: What are your telecommunication goals through participation in the NDBEDP? 1.Name of person completing application (if other than applicant) 2.Relationship: 3.Telephone Number (include area code) Is this numer a Voice, VP, TTY, or Fax number 4.Email Address: 5. Alternate contact person (for applicant): 6.Relationship: 7.Telephone Number for alternate contact person: Is this numer a Voice, VP, TTY, or Fax number 8.Email Address: Application Section 6 of 6. Disability Verification: This disability verification section is to be completed by a practicing professional who has direct knowledge of the applicant’s vision and hearing loss. Please complete the following sections, then sign and date. Name and Address of Deaf-Blind Individual Name of Applicant: Street Address: City/State/Zip Code: Attester Information: Name of Attester: Title: Agency/Employer: City/State/Zip Code: Street Address: City/State/Zip Code: E-Mail: Telephone (include area code): For this program, Twenty-First Century Communications and Video Accessibility Act of 2010 (CVAA) requires that the term “deaf-blind” has the same meaning given by the Helen Keller National Center Act. In general, the individual must have a certain vision loss and a hearing loss that, combined, cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working). Specifically, the FCC’s NDBEDP rule 64.6203(c) states that an individual who is “deaf-blind” is: (1) Any individual: i. Who has 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; ii. Who has 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 iii. for whom the combination of impairments described in . . . (i) and (ii) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation. (2) An individual’s functional abilities with respect to using Telecommunications service, Internet access service, and advanced communication services, including interexchange services and advanced telecommunications and information services in various environments shall be considered when determining whether the individual is deaf-blind under . . . (ii) and (iii) of this section. (3) The definition also includes any individual who, despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional and performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives. I certify under penalty of perjury that, to the best of my knowledge, this individual is deaf-blind as defined by the FCC as above (and as previously referenced Section 1). My attestation is based on the following: Attester Signature: Date: Mail completed application to: Access Technologies, Inc. ATTN: NDBEDP 2225 Lancaster Drive NE Salem, OR 97305 OR email completed application to: info@accesstechnologiesinc.org OR fax completed application to: 503-370-4530 If scanned documents are emailed, please use PDF format. Questions, please call our office at 503.361.1201 This information is available in alternate format upon request. hearing and vision loss stay connected to friends, family and the world. The appearance of a specific piece of equipment listed here does not mean that it is appropriate for every program participant. iCanConnect-Oregon Specialists will work with individual consumers to identify the equipment that addresses each person’s specific need. Accessories Accessories includes specialized keyboards, mounts, switches, headset and other support devices. Braille Devices Braille equipment provided through the iCanConnect program includes a wide array of refreshable displays and sophisticated multipurpose devices, that enhances access to distance communication. Some can be used as stand-alone devices connected via Wi-Fi, while others are paired with a mobile device to provide tactile access to email, text messaging, and other modern communication resources enjoyed by the general public. To receive braille equipment, an eligible consumer must be proficient in braille and must have access to the internet or cellular service. Computers iCanConnect-Oregon provides both Windows and Apple computers, including desktops and laptops, to eligible consumers who have Internet access. The program can also provide a large monitor if needed. Mobile Devices This category includes cell phones, smartphones, tablets, and associated accessories such as keyboards and protective cases. iCanConnect-Oregon provides the equipment, but the consumer must pay for his or her own internet or cellular service. Phones This category includes a variety of amplified speaker phones, cordless phones, and related devices that connect to the “landline” telephone service. An eligible consumer must have telephone service to be considered for this type of equipment. Signalers This category includes audible, visual, and vibrating signalers that alert the user to a phone ringing, new email, or other types of distance communication. Software This category includes screen readers and screen magnifier programs. A screen reader can serve as an interface between a computer and a braille display, and for those with usable hearing, it also provides synthesized speech output of what is on the computer screen. The user interacts with the screen reader and computer via a complex set of keyboard commands. A screen magnifier selectively enlarges what is on the computer screen to enable access by individuals with very limited vision. Privacy Statement The Federal Communications Commission (FCC) collects personal information about individuals through the National Deaf-Blind Equipment Distribution Program (NDBEDP), a program also known as iCanConnect. The FCC will use this information to administer and manage the NDBEDP. Personal information is provided voluntarily by individuals who request equipment (NDBEDP applicants) and individuals who attest to the disability of NDBEDP applicants. This information is needed to determine whether an applicant is eligible to participate in the NDBEDP. In addition, personal information is provided voluntarily by individuals who file NDBEDP-related complaints with the FCC on behalf of themselves or others. When this information is not provided, it may be impossible to resolve the complaints. Finally, each state’s NDBEDP-certified equipment distribution program must submit to the FCC certain personal information that it obtained through its NDBEDP activities. This information is required to maintain each state’s certification to participate in this program. The FCC is authorized to collect the personal information that is requested through the NDBEDP under sections 1, 4, and 719 of the Communications Act of 1934, as amended; 47 U.S.C. 151, 154, and 620. The FCC may disclose the information collected through the NDBEDP as permitted under the Privacy Act and as described in the FCC’s Privacy Act System of Records Notice at 77 FR 2721 (Jan. 19, 2012), FCC/CGB-3, “National Deaf-Blind Equipment Distribution Program (NDBEDP),” https://www.fcc.gov/omd/privacyact/documents/records/FCC-CGB-3.pdf. This statement is required by the Privacy Act of 1974, Public Law 93-579, 5 U.S.C. 552a(e)(3).