National Deaf-Blind Equipment Distribution Program Application Instructions

National Deaf-Blind Equipment Distribution Program Application 
Removing communication barriers for people who are Deaf, Hard of Hearing, Late-Deafened, Deaf-Blind or Speech Disabled

The National Deaf Blind Equipment Distribution Program (NDBEDP) is a national program required by the Twenty-First Century Communications and Video Accessibility Act (CVAA) that provides $10 million annually for the distribution of communications equipment to low-income individuals who are deaf-blind. The Office of the Deaf and Hard of Hearing (ODHH) has been selected by the Federal Communication Commission (FCC) to administer the NDBEDP.  Washington State will receive approximately $197,000 for the first year of the two-year NDBEDP pilot project.

Applicant must meet the following criteria to be eligible to participate in the NDBEDP:

Verification of Disability: Applicants must meet the Helen Keller National Center (HKNC) definition of Deaf-Blind which states an individual is Deaf-Blind when they:
 
1. Have 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; 

2. Have 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. Have the combination of impairments described in 1 and 2 above cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining a vocation.  

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. 

2012 Federal Poverty Guidelines for Washington
(table with two columns, first column is Number of persons in family/household, second column is 400% of the Federal Poverty Guidelines.

1. $44,680

2. $60,520

3. $76,360

4. $92,200

5. $108,040

6. $123,880

7. $139,720

8. $155,560

For each additional person, add	$15,840
Source: Adapted from U.S. Department of Health and Human Services (aspe.hhs.gov/poverty/12poverty.shtml)

Filling out the application

Please read the instructions and review the application.
Complete the application and send it to ODHH, ATTN: NDBEDP at the Olympia WA address below.

This section gives step-by-step instructions for filling out the NDBEDP Application (pages 5 - 7).  
Instructions below are written so that "You" means the person who is applying for telecommunication equipment.

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.

Regional Service Centers (RSC) for the Deaf and Hard of Hearing
The Office of the Deaf and Hard of Hearing (ODHH) supports eight(8) Regional Service Centers (RSC) in the State of Washington. RSC Advocates work with people who are Deaf, Hard of Hearing, Late-Deafened, and Deaf-Blind. You may contact your local RSC for help filling out the application.
  
Advocates may also sign the professional certification on page 7, section 6 of the application.
Contact ODHH to find the RSC in your area:

ODHH
PO Box 45301
Olympia, WA 98504-5301
(800)422-7930 V/TTY
(360)902-8000 V/TTY
(360)902-0855 FAX
(360)339-7382 VP
E-mail:ndbedp@dshs.wa.gov 
Web:http://odhh.dshs.wa.gov

Instructions for completing the Application for Telecommunication Equipment

Section 1.  Information

1. Name. 
Enter your last name, 
first name, 
and middle initial.

2. Gender. Select your gender. 
Check: 
male or 
female.

3. Address. 
Enter your home address: 
Street, 
City, 
State, 
and Zip Code. You must enter a 5-digit zip code. You may enter a 9-digit zip code, if known.

4. Mailing address. 
Enter your mailing address (same format as #3), if different than your home address.  Mailing address may be a Post Office box, Rural Route, or other location where you receive mail.

5. Community/facility name. 
Enter the name of the facility you live in.  A "facility" may be an apartment complex, adult family home (AFH), or nursing home.

6. County. Enter the county you live in.

7. Home telephone number. 
Enter your home telephone number, in the following format: (area code) phone number.  Check the type of phone number it is: Voice, TTY, Fax, or Video Phone (VP).
 
8. Message telephone number. 
Enter a message telephone number where ODHH may call to leave messages for you.

9. E-mail address. 
Enter your e-mail address, if you have one. ODHH may contact you by e-mail, if necessary.

10. Best times to contact. 
Enter best times to contact you. ODHH will contact you during that time, if possible.

11. Social Security Number (optional). 
Enter your Social Security Number (SSN).This is optional.

12. Date of Birth. 
Enter your Date of Birth in the following format: MM/DD/YYYY (example: 12/06/1981).

13. Race/Ethnicity (optional). 
Check the box that best describes your race or ethnicity. This is optional.

14. Federal Program Participation.  Please check all programs you currently receive benefits from.

15. Income Eligibility. Enter your Household size (number of individuals living at the same address), and all sources of income from each individual: 
monthly and estimated annual (one year) income.  You must complete this section. You must provide proof of income in the form of pay stubs, 
most recent tax return, 
SSI, SSDI, or 
other benefits documentation.  
You can contact ODHH if you have questions about other documents you may be able to use to prove income.  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 allowances, irregular income from occasional small jobs 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.

To confirm your income eligibility, please mail or fax a copy of last year’s Federal 1040 IRS tax form, or send documentation that provides your eligibility for one of the following federal low-income programs:

* Medicaid
* Low income home energy assistance
* SSI
* Federal public housing assistance or Section 8
* Food Stamps or SNAP (Supplement Nutrition Assistance Program)
* Temporary Assistance for Needy Families (TANF) or Welfare to Work (WTW)

If none of the above apply, last year’s Social Security Administration benefit statement or other pension benefit statement.

Section 2. Profile
1. Hearing Loss.  Check the box that best describes your level of hearing

2. Vision.   Check the box that best describes your vision.

3. Hand Coordination.  
Check whether or not you have difficulty using your hands for keyboarding, 
dialing the phone, or 
holding small objects.

4. Communication Preference. 
Check all boxes that identify the Client's communication preferences.  See below for definitions of the different types of communication preferences. American Sign Language (ASL): 
Visual and gestural language with linguistic rules that are different from English and any other language. 
ASL is used by Deaf people in the United States and some parts of Canada.

Pidgin Sign Language (PSE): A form of sign language that arises from contact between ASL and spoken English.

Sign Exact English (SEE): Visual and manual communication that represents the English language, verbatim.

High Visual Communication Skills (HVCS/MLS): Use of gestures, visual concepts, or home signs. 
Generally, people with HVCS do not know ASL and/or spoken/written English.  Formerly known as Minimal Language Skills.

Tactile Sign Language: A Deaf-Blind person places their hand over another person's hand who is signing. 
This allows a Deaf-Blind person to receive signed visual and expressive communication from a person.

Close-Vision Sign Language: A Deaf-Blind person with usable, limited field of vision who can see a person signing within a limited distance. Depending on visual needs, a person may sign using a limited or larger signing space.

Spoken Language: Communicate by speech, sometimes the oral approach. The person may use auditory aids, such as digital hearing aids, cochlear implants, and lip-reading to communicate.  If the client speaks a foreign language, identify the foreign language.

International Sign Language: A sign language used by a person from another country, who does not communicate in ASL or English.

Other: Other form of communication not listed.

5. Reading. Check the boxes that indicate what formats you currently read.

Section 3. Communication Methods

1. Communication activities. Check all current activities you perform.

2. Communication equipment. Check all equipment you currently use.

Section 4. Program Goals
Please describe what type of communication access you hope to achieve by participation in the NDBEDP.

Section 5. Client Signature

1. Signature and date. 

You must sign and date the application. 

If you are unable to sign and date the application, 

the person who is filling out the application for you may sign on your behalf.

2. Person completing the application. 

If you are not filling out the application for yourself, 
the person who is filling out the application must enter: 
their name, 
relationship to you, 
telephone number, 
including area code, 
and e-mail address, if available.

3. Alternate contact person. 

Enter information for an alternate contact person, 
if available (same format as #2). 
TED will use this information to contact you, 
leave messages, or 
schedule appointments for you, if necessary.

Section 6. Professional Certification

Check the box that describes the profession of the individual signing the application form.  WAC 388-818-010 states that the following individuals are authorized to certify an applicant's eligibility:

a. A person who is licensed or certified by the department of health to provide health care in the state of Washington;

b. An audiologist or hearing aid fitter/dispenser in Washington;

c. A deaf specialist or coordinator at one of the community service centers for the deaf and hard of hearing in the state;

d. Any in-state nonprofit organization serving the hearing or speech impaired.

e. Staff from a qualified state agency;

f. A vocational rehabilitation counselor;

g. A deaf-blind specialist or coordinator at an organization that serves deaf-blind people;

h. A licensed occupational therapist;

i. Other: write-in your profession.

When you've completed your Application, send pages 5 - 7 to ODHH.



NATIONAL DEAF-BLIND EQUIPMENT DISTRIBUTION PROGRAM APPLICATION INSTRUCTIONS, DSHS 14-533 (01/2013)