iCanConnect – Oregon

Application Section 1of 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?
Under the CVAA, only low-income individuals who are deaf-blind are eligible to receive equipment provided through the NDBEDP. Applicants must provide verification of their status as low-income and deaf-blind.

Income Eligibility:
To be eligible, your family/household income must be below 400% of the Federal Poverty Guidelines, as listed under 2022 Federal Poverty Guidelines.

2022 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 - $54,360
2 - $73,240
3 - $92,120
4 - $111,000
5 - $129,880
6 - $148,760
7 - $167,640
8 – $186,520
For each additional person, add $18,880
Source: U.S Department of Health and Human Services


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.

See Section 3 for the family/household income information that must be provided with this application: either 1) proof of your current participation in a federal low-income program whose income limit is below 400% of the Federal Poverty Guidelines, or 2) proof of household income.

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 64.6203(c) states that an individual who is “deaf-blind” is:

Any individual:
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:

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

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.

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 individual’s functional abilities with respect to using telecommunications service, internet access, and advanced communication services in various environments shall be considered when determining whether the individual is deaf-blind under (ii) and (iii) of this section.


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
Educator
Community-based service provider
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.  

See Section 6 for the disability attestation information that must be provided with this application. If you disagree with the professional’s disability decision, please call Access Technologies, Inc. at 503-361-1201 or 1-800-677-7512, or send an email to info@accesstechnologiesinc.org


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?
You may ask another person to fill the application out for you. Note: The individual 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 provide the following details for lines 1 – 22.

1. Applicant’s Full Name:

2. Applicant’s Date of Birth:

3. Applicant’s Gender: 

4. Applicant’s Home Address (Including City/State/Zip Code):

5. If Applicable, Please Note the Community / Facility Name (i.e., nursing home, apartment complex) Associated with Applicant’s Home Address:



6. Applicant’s Mailing address, (Including City/State/Zip Code): (if different):

7. Applicant’s Home Telephone Number (including area code): 

8. Note if Applicant’s Home Telephone Number is a VOICE or VP number:

9. Provide a Message Telephone Number:

10. Note if Applicant’s Message Telephone Number is a VOICE or VP number:

11. Applicant’s E-mail Address:

12. What is the Best Time to Contact You?

13. Indicate Whether Your Preferred Method of Contact is By Telephone, Your Message Telephone, or By Email.

14. Note Which State You Are a Permanent Resident Of:

15. Have You Participated in iCanConnect (The National Deaf-Blind Equipment Distribution Program) Before?

16. If Yes, What State/States Have You Participated In iCanConnect? (List all)?

17. Did You Previously Receive Equipment Through ICanConnect In Another State?

18. If Yes, What State/States Did You Receive Equipment Through ICanConnect? (List All)?

19. 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:

20. If You Selected Other Language, Please Describe.:

21. Which Format Do You Prefer for Written Correspondence (Braille, Email, Large Print, Standard Print, Other):

22. If You Select Other Format, Please Describe:


Please provide the following alternate contact information for lines 1 – 4, in case of an emergency:

1. Alternate Contact Person:

2. Alternate Contact Person’s City/State/Zip Code:

3. Alternate Contact Person’s Primary Telephone Number:

4. Alternate Contact Person’s Email Address:

Application Section 3 of 6: Program Goals:

What are your telecommunication goals through participation in the NDBEDP?


APPLICATION SECTION 4 of 6 Income Eligibility:

NOTE: Income eligibility is valid for ONE year.

To confirm your income eligibility, please provide 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, provide 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).

How many people are living in your household?


APPLICATION SECTION 5 of 6 Applicant Attestation (Signature Required) You may request ATI to obtain your signature during the onsite assessment.

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).

1. Print name of applicant (or parent/guardian if applicant is under age 18):

2. Signature of applicant (or parent/guardian if applicant is under age 18):

3. Date you are signing application:

4. If the application is completed by someone other than the applicant, please state 
your name:


NOTE: By affixing my name above, I certify that I am signing this application for the applicant and with the applicant’s knowledge and consent.

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.

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.

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).


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.

1. Name of Applicant:

2. Name of Attester:

3. Title of Attester:

4. Agency/Employer:  

5. City/State/Zip Code:  

6. E-Mail:   

7. Primary 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.

My attestation is based on the following: (Please state how you are familiar with each of the applicant’s hearing and vision loss, AND the applicant’s combination of hearing and vision loss, as defined in the FCC’s NDBEDP rules listed directly above.


1. Vision Loss:

2. Hearing Loss:

3. Describe how the combination of hearing and vision loss affects this person in daily life. (See definitions in this section):


NOTE: 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).

Attester Signature:

Date:

Send Completed Application  (Sections 2, 3, 4, 5, and 6) to:

By Mail:
Access Technologies, Inc.           
2225 Lancaster Drive NE            
Salem, OR 97305

By Fax:
Fax:  503-370-4530

By Email:
Email:  info@accesstechnologiesinc.org
If submitting scanned documents, please use PDF format.

Questions, please call our office at 503.361.1201
Rev. January 2022  Page 3 of 8


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