National Deaf-Blind Equipment Distribution Program Application

When you have completed the application, mail pages 5-7 to: 
ODHH - NDBEDP
PO BOX 45301
Olympia, WA  98504-5301
 
Section 1. Applicant's Information
1. Last name
first name
middle initial 
     
2. Gender 
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) 
     
6. County  
     
7. Home phone number (include area code) is this 
Voice	
VP	
TTY
FAX

8. Message phone number (include area code) is this 
Voice 
VP
TTY
FAX

9. E-mail address
 
10. Best times to contact
  
11. Social Security Number (optional)
 
12. Date of Birth (MM/DD/YYYY)
 
13. Are you of Hispanic origin?  
Yes    
No

The Spanish/Hispanic/Latino question is about ethnicity, not race. 
Please continue to answer the following question by marking one or more boxes to indicate what you consider your race to be (circle all that apply):
White	
Black or African American	
American Indian or Alaskan Native  
Native Hawaiian or Pacific Islander	
Asian	
Other race

14. Federal Program Participation:   Do you receive any of the following:
Medicaid
Low income home energy assistance
SSI/SSDI
Federal public housing or Section 8
Food Stamps or Supplemental Nutrition Assistance (SNAP)
Temporary Assistance for Needy Families (TANF) Program or Welfare to Work (WTW) 

15. Income Eligibilty:

Annual income:$     		
Household size:       
Attach proof of income. See instructions, page 3 for more information.

Section 2. Profile
1. Hearing loss (please circle best describes your level of hearing):
Deaf	
Hard-of-hearing  
Late deafened  
Can understand speech
How old were you when this level of hearing loss was noticed?  
     
2. Vision loss (please circle the level that best describes your vision):
Blind  
Low vision  
Close vision  
Tunnel vision	
How old were you when you noticed this level of vision was noticed?   
    
3. Do you have any difficulty using your hands for keyboarding, dialing the phone, or holding small objects?   
Yes   
No

4. Communication preference (circle all that apply):
American Sign Language (ASL)
Pidgin Sign Language (PSE)
Sign Exact English (SEE)
High Visual Communication Skills (HVCS)/(MLS)
Tactile Sign Language
Close-Vision Sign Language
Spoken Language; if you speak a foreign language, specify:
International Sign Language (specify):
Other (specify):
	     
5. How do you read? (Please circle all that apply):
Regular print
Large print	
Computer Braille	
Braille grade 1 (Uncontracted)	
Braille grade 2 (Contracted)     

Section 3. Communication Methods
1. Which of these activities do you currently perform?  Please circle all that apply.
TTY calls by landline telephone	
Videophone	
TTY calls by web/computer	
Text messaging
TTY calls by instant messaging programs
Instant messaging
Relay calls by landline telephone
Email
Relay calls by web/computer
Internet surfing / searching
Relay calls by instant messaging programs
Other:       

2. What equipment do you use to perform the above tasks?  Please circle all that apply.
TTY
Computer with speech screen reader 
Video Equipment
Computer with Braille display 
DBC
iPad or other tablet device 
Computer with screen magnification
iPhone or other smart phone

3. Do you have an Internet connection in your home that you can use?
Yes
No

Section 4. Program Goals
What is your communication goal through participation in the NDBEDP?       

Section 5. Client Signature
1. Signature 
and Date
	     
2. Person completing application (if other than applicant)

Name	
Relationship
Telephone number (include area code) 
Voice
VP
TTY
FAX
Email address

3. Alternate contact person (for applicant)
Name	
Relationship
Telephone number (include area code) 
Voice
VP
TTY
FAX
Email address

     
Section 6.  Professional Certification
Professional must sign the application.
By signing below, you certify you have direct knowledge that the applicant's disability meets the following definition of Deaf-Blind. 

Definition of Deaf-Blind for the purpose of NDBEDP. 
 
To apply for participation in the NDBEDP, the HKNC Act defines an "individual who is deaf-blind" as any individual:

1. 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; 

2. 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

3. For whom 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.  

1. Professional information:
Doctor
Deaf Specialist
State Agency Employee
Deaf-Blind Specialist
Audiologist
Non-Profit Rep
Voc Rehab Counselor
Occupational Therapist
Other:       

2. Professional signature	
Date	
Printed Name and title 
Mailing address
E-mail address   	
Telephone number (include area code) 
Voice
VP
TTY
FAX
License/certificate number
     

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