The National Deaf-Blind Equipment Distribution Program Eligibility Guidelines

iCanConnect Delaware

The National Deaf-Blind Equipment Distribution Program

Eligibility Guidelines

The National Deaf-Blind Equipment Distribution Program (NDBEDP) supports local programs that distribute equipment to low-income individuals who are deaf-blind to enable access to telephone, advanced communications, and information services. This support was mandated by the Twenty-First Century Communications and Video Accessibility Act of 2010 (CVAA) and is provided by the Federal Communications Commission (FCC). The Center for Disabilities Studies (CDS) was selected by the FCC to administer the NDBEDP in Delaware. CDS has partnered with Delaware’s Division for the Visually Impaired (DVI) and Delaware Program for Children with Deaf-Blindness in order to administer the program. For more information on about NDBEDP program go to http://www.fcc.gov/ndbedp or http://www.icanconnect.org.

1 Disability Eligibility For this program, the 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 64.610(c)(2) states that an individual who is “deaf- blind” is: (i) Any person: (A) 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; (B) 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 (C) For whom the combination of impairments described in … (A) and (B) of this section cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.

04/25/2017 1 (ii) The definition in this paragraph 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.

An applicant's functional abilities with respect to using telecommunications, Internet access, and advanced communications services in various environments shall be considered when determining whether the individual is deaf-blind under … (B) and (C) of this section.

2 Income 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.

2017 Federal Poverty Guidelines Number of persons in family/household and allowable income level at 400% of the Federal Poverty Guidelines for everywhere except Alaska and Hawaii. Household Size Household Income 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 families/households with more than 8 persons, add $16,720 for each additional person Source: U.S. Department of Health and Human Services https://aspe.hhs.gov/poverty- guidelines For purposes of determining income eligibility for 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

04/25/2017 2 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.

3 Confidentiality Policy iCanConnect Delaware is committed to ensuring that your privacy is protected. Information provided on your application form will only be used to determine eligibility for iCanConnect products and services. 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. iCanConnect is 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 iCanConnect collects.

4 Applying for Services If you think you or someone that you know is eligible contact Sonja L Rathel at 302-856- 1081; or email [email protected] for an application..

Do you need help? 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 are 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.

5 Help in Finding Equipment to Meet Your Needs

Several organizations are working together to help you figure out the best equipment for your needs. These include the Delaware Division for the Visually Impaired, the Delaware Program for Children with Deaf-Blindness, and the Delaware Assistive Technology Initiative at the University of Delaware’s Center for Disabilities Studies. If you already have a relationship with one of these organizations, contact them for an application. They will work with the other partners to help you make good equipment decisions. See contact information for these organizations below.

Elisha Jenkins 04/25/2017 3 DHSS/Division for the Mark Campano Sonja Rathel Visually Impaired Delaware Program for DATI/University of Delaware 1901 N DuPont Hwy Children with Deaf- Center for Disabilities Biggs Building Blindness Studies New Castle, DE 19720 630 E Chestnut Hill RD 20123 Office Circle [email protected] Newark, DE 19713 Georgetown, DE 19947 302-255-9813 Voice [email protected] [email protected] 302-255-9854 TDD e.us 302-856-1081 Voice 302-255-9388 Fax 302-454-2305 Voice 302-856-6714 TDD 302-722-4317 VP 302-856-6990 Fax 302-454-2497 Fax

04/25/2017 4 iCanConnect Delaware

National Deaf-Blind Equipment Distribution Program

Application iCanConnect 21. Race/Ethnicity (optional, not required) Are you of Hispanic origin? ☐ Blank ☐ Formatted ☐ Text-onlyThe Spanish/Hispanic/Latino question is about ethnicity, not race. Please continue to answer the Delaware following question by marking one or more boxes to indicate what you consider your race to be 12. Alternate Contact Name: (select only one): ☐ White ☐ Black or African American ☐ Native Hawaiian or Pacific Islander 14. Phone: 22. Are you currently being served by another service system? If yes, does your current equipment choice used in another setting continue to meet your Review the National Deaf- telecommunications needs? ☐ Yes ☐ No Blind Equipment Distribution 16. Alternate Contact’s address Will you give us permission to contact others who may have information relative to your Program Eligibility application? ☐ Yes ☐ No

Guidelines for more detail 17. Applicant’s Language Preference:23. Have you participated in iCanConnect (the National Deaf-Blind Equipment Distribution ☐ Unknown Program) before? ☐ Yes ☐ No before beginning this ☐ English – Spoken ☐ American Sign LanguageIf (ASL) yes, in which state(s) did you participate in iCanConnect? (list all) application process. ☐ Signed English Section 1. Applicant’s Information ☐ Spanish – Spoken Income Eligibility ☐ No Formal Language 1. Last name, first name, middle initial ☐ Tactile ASL/PSE Number of persons in family/household and allowable income level at 400% of the Federal ☐ Close Vision ASLP/PSE Poverty Guidelines for everywhere except Alaska and Hawaii. ☐ Pidgin Signed English 2. Date of Birth ☐ Other (describe) For families/households with more than 8 persons, add $16,720 for each additional person.

4. Home address Source: U.S. Department of Health and Human Services. For more information, and to see the allowances for Alaska and Hawaii, go to https://aspe.hhs.gov/poverty-guidelines

Household Size Household Income 5. Mailing address (if different) 20. How City did you hear about this program? 1 $48,240 ☐ iCanConnect.org website 2 $64,960 ☐ Conference or seminar 3 $81,680 6. Community/Facility name (i.e., nursing☐ Disability Advocacy Group 4 $98,400 home, apartment complex) ☐ Education Provider/School 5 $115,120 ☐ Family Member 6 $131,840 ☐ Friend 7 $148,560 8. Home phone number (include area code)☐ Healthcare Provider 8 $165,280 ☐ Helen Keller National Center (HKNC) Representative ☐ Voice ☐ VP ☐ Voice & Text ☐ Independent Living CenterApplicant’s annual gross household income: ☐ TTY ☐ FAX ☐ Relay ☐ Interpreter ☐ Text Messaging Please mail or fax documentation that proves your eligibility for one of the following federal programs. 10. E-mail address: ☐ Low Income Home Energy Assistance ☐ Medicaid (B) Who has a chronic hearing impairment so severe that most speech cannot be ☐ Federal Public Housing Assistance (Sec 8) understood with optimum amplification, or a progressive hearing loss having a prognosis Telephone number (include area code) andleading to this condition; and ☐ Food Stamps or Supplemental Nutrition Assistance Program (SNAP) preferred method (C) For whom the combination of impairments described in … (A) and (B) of this section ☐ Supplemental Security Income (SSI) cause extreme difficulty in attaining independence in daily life activities, achieving ☐ Temporary Assistance for Needy Families (TANF) or Welfare to Work (WTW) ☐ Voice ☐ VP ☐ Voice & Text psychosocial adjustment, or obtaining a vocation. ☐ National School Lunch Program’s☐ TTY free ☐ lunch FAX program☐ Relay (ii) The definition in this paragraph also includes any individual who, despite the inability to ☐ Veterans and Survivors Pension☐ Text Benefits Messaging 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 Email of person completing application (if other independence in daily life activities, achieving psychosocial adjustment, or obtaining If none of the above applies, mail orthan fax applicant: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 family/householdvocational objectives. income, such as recent Social Security Administration retirement benefit statement(s) or other Section 3. Verification of Disability (to Anbe applicant'scompleted functional by a professional) abilities with respect to using telecommunications, Internet pension benefit statement(s). Include a signed statement that attests that whataccess, you are and submitting advanced communications services in various environments shall be is your only source of income. considered when determining whether the individual is deaf-blind under … (B) and (C) of Section 2. Applicant Signature Note: Send documentation that provesthis eligibility section. with this application With my signature below, Select your profession… I certify under penalty of perjury that, to the best of my knowledge, this individual is deaf-blind as 1) I certify that all information provided☐ on Audiologist this application, includingdefined information by the aboutFCC as my above. disability and income, is true, complete,☐ Community-based and accurate to theService best of my knowledge. I authorize program representatives Providerto verify the information provided;Professional signature Date Printed Name 2) I permit information about me to be☐ shared Educator with my state's current and successor program managers and representatives for the administration of the program and for the delivery of ☐ Hearing Professional equipment and services to me. I also permit information about meProfessional to be reported title to the Federal Communications Commission☐ HKNC for the Representative administration, operation, and oversight of the program; ☐ Medical/Health Professional 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 anotherAgency person Name: any equipment provided to me by the program; Qualification Note: 4) If I provide any false records or fail to comply with these or otherEmail: 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 Street Address: officials may take legal action against me; and, 5) I certify that I have read, understand, and accept these conditions to participate in For this program, the CVAA requires that the term "deaf-blind" has the same meaning given by iCanConnect (the National Deaf-Blind Equipment Distribution Program). the Helen Keller National Center Act.City, In State,general, Zip: the individual must have a certain vision loss 1. Print name of applicant or parent/guardianand a hearing (if applicantloss that, iscombined, under age cause 18): extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation (working).

Specifically, the FCC’s NDBEDP rule 64.610(c)(2) states that an individual who is “deaf-blind” is: 2. Signature Date (i) Any person: (A) Who has a central visual acuity of 20/200 or less in the better eye with corrective 3. Person completing application (if otherlenses, than or a field defect such that the peripheral diameter of visual field subtends an applicant) angular distance no greater Submitthan 20 degrees,the completed or a progressive application visual and loss supporting having a documents to: Name Relationship to Applicantprognosis leading to one or both these conditions; Sonja L Rathel DATI/University of Delaware Center for Disabilities Studies 20123 Office Circle Georgetown, DE 19947

6 information is provided Law 93-579, 5 U.S.C. 552a(e) 7 P voluntarily by individuals who (3). ri file NDBEDP-related complaints v with the FCC on behalf of a themselves or others. When this information is not provided, it c may be impossible to resolve y the complaints. Finally, each S state’s NDBEDP-certified t equipment distribution program a must submit to the FCC certain t personal information that it obtained through its NDBEDP e activities. This information is m required to maintain each e state’s certification to participate n in this program. t The FCC is authorized to collect The Federal Communications the personal information that is Commission (FCC) collects requested through the NDBEDP personal information about under sections 1, 4, and 719 of individuals through the National the Communications Act of Deaf-Blind Equipment 1934, as amended; 47 U.S.C. Distribution Program 151, 154, and 620. (NDBEDP), a program also The FCC may disclose the known as iCanConnect. The information collected through FCC will use this information to the NDBEDP as permitted administer and manage the under the Privacy Act and as NDBEDP. described in the FCC’s Privacy Personal information is provided Act System of Records Notice at voluntarily by individuals who 77 FR 2721 (Jan. 19, 2012), request equipment (NDBEDP FCC/CGB-3, “National Deaf- applicants) and individuals who Blind Equipment Distribution attest to the disability of Program (NDBEDP),” NDBEDP applicants. This https://www.fcc.gov/omd/privacy information is needed to act/documents/records/FCC- determine whether an applicant CGB-3.pdf. is eligible to participate in the This statement is required by NDBEDP. In addition, personal the Privacy Act of 1974, Public