Form OMB Control 1820-0 OMB Control 1820-0 Annual Performance Report

Rehabilitation Services Administration

Annual Progress Report for

State Grants for Assistive Technology

Public Reporting Burden

OMB # 1820-0572

Expires:

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 402 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required under the Assistive Technology Act of 1998, as amended to retain benefit of the State Grant for Assistive Technology Program. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0572.

This document was prepared by the Center for Assistive Technology Act Data Assistance under Grant No. H224B110002 from the U.S. Department of Education

Table of Contents

General Information 1

State Financing 2

Reuse 18

Device Loans 21

Device Demonstrations 26

Overall Performance Measures 30

Training 31

Technical Assistance 35

Public Awareness and Information and Assistance 38

State Improvement Outcomes 40

Additional and Leveraged Funds 41

Data Collection Instrument Access Performance Measure 43

Data Collection Instrument Acquisition Performance Measure 44

Data Collection Instrument IT/Telecommunications Training Performance Measure 46

Survey Instrument Customer Satisfaction 47

Instructions for completion of this form and relevant definitions are contained

in a separate document, “Instruction Manual and Definitions for the Annual Progress Report for State Grants for Assistive Technology.”

General Information

1. General Information
Statewide AT Program
1. State and Program Title
Lead Agency
2. Agency name
3. Mailing address	8. Fax
4. City	9. Program URL
5. State	10. Program E-mail
6. Zip code	11. Program toll-free number  Check if in state only
7. Phone	12. Program TTY number
Implementing Entity
13. Check here if not applicable. If applicable, complete Items 14–24.
14. Name of implementing entity
15. Mailing address	20. Fax
16. City	21. Program URL
17. State	22. Program E-mail
18. Zip code	23. Program toll-free number  Check if in state only
19. Phone	24. Program TTY number
Program director and other contacts
25. Program Director at Lead Agency (last, first)
26. Title
27. Phone
28. E-mail
29. Name of Program Director at Implementing Entity (last, first) – If applicable
30. Title
31. Phone
32. E-mail
Person Responsible for completing this form is other than Program Director
33. Name (last, first)
34. Title
35. Phone
36. E-mail
Certifying Representative
38. Name (last, first)
39. Title
40. Phone
41. E-mail

State Financing

Outline

Overview of Activities Performed

A. Financial loan programs

1. Loan applications

2. Income of applicants to whom loans were made

3. Loan type

4. Interest rates

5. Types and dollar amounts of AT financed

6. Defaults

7. Additional Data for Title III Funded AFP

B. State financing activities that provide consumers with resources and services that result in the acquisition of AT devices and services

1. Overview of Activities Performed

2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and Services and Number for whom Performance Measure Data are Collected

3. Types and dollar amounts of AT funded

C. State financing activities that allow consumers to obtain AT at a reduced cost

1. Overview of Activities Performed

2. Geographic Distribution and Number of Individuals Served

3. Savings to consumers, by type of AT device/service

D. Anecdote

E. Performance measures

F. Customer Satisfaction

G. Notes

Section 4f requirements: (1) the type of State financing activities…used by the State; (2) the amount and type of assistance, including the number of applications for assistance received, the number of applications approved and rejected, the default rate for the financing activities, range and average interest rate for the financing activities, range and average income of approved applicants for the financing activities, and the types and dollar amounts of AT financed; (3) consumers of the State financing activities, who shall be classified by type of AT device or service and geographical distribution

A state financing activity is an activity approved as part of your State Plan for AT, such as the development of systems: to provide and pay for AT, for the purchase, lease, or other acquisition of, or payment for AT; or of State-financed or privately financed alternative financing systems of subsidies.

Examples of state financing activities include, but are not limited to administering financial loan programs, administering “last resort” activities funded with non-AT Act dollars, administering cooperative buying programs, administering telecommunications distribution programs, and other activities designed to provide consumers with resources and services that result in the acquisition of AT devices and services.

Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting any State Financing activities? – check yes or leave unchecked. If yes complete one or more of sections A, B, or C.

1. Financial Loan Programs

Did your approved State Plan include conducting a financial loan program? (Do not include Access to Telework in this report.) – check yes or leave unchecked.

If yes -- is this financial loan program a Title II Alternative Financing Program? – check yes or leave unchecked. If only the first question is checked yes, Items 1-6 of Section A will be completed. If both questions are answered yes, Item 7 of Section A will also be completed.

1. Loan Applications

In this section, report on: (1) revolving loans that are made directly by the Statewide AT Program; and (2) partnership loans that use dollars from another source, usually a financial institution, in which the statewide AT program has an investment through loan guarantee, agreement with a financial institution based on an investment deposit, interest or principal buy-down, or other financial or administrative role. Do not include loans in which the statewide AT program had no financial or administrative role, such as loans for which you simply made a referral to a lending source.

In the table below, report information on loan applications made by Rural Urban Continuum Code (RUCC) of the applicant’s county of residence and the decisions made about those applications. Include all applications that were processed to one of the three decisions shown in the table below (i.e., approved—loan not made, approved—loan made, or rejected) during this reporting period, even if the application was received prior to the start of the reporting period. Do not include applications that were not reviewed because they were not complete, were withdrawn before a final decision was made, or were still pending at the end of the reporting period. For guidance on how to classify the applicant’s area of residence as metro or non-metro, please see the “General Instructions.”

Number of Applications	Area of Residence		Total
	Metro RUCC 1-3	Non-Metro RUCC 4-9
Approved—loan made			System-generated
Approved—loan not made (i.e., the application was withdrawn after the loan was approved, or the loan was approved but not accepted by the consumer)			System-generated
Rejected			System-generated
Total	System-generated	System-generated	System-generated

Income of Applicants to Whom Loans Were Made

This section collects data about the income of applicants to whom loans were made (i.e., those who were counted in row A of the table in Section B, Item 1above). For purposes of this section, the income of these applicants is the gross annual income that the applicants reported on the loan applications (i.e., the amount upon which the decision about the loan was based). This may be the income of the individual, the family, and/or one or more co-borrowers.

1. Enter the lowest and highest income reported among all applicants to whom loans were made during the reporting period:

Lowest: $______________

Highest: $______________

2. Use the table below to calculate the average gross annual income of applicants to whom loans were made. In Column A, enter the sum of the incomes reported by all applicants to whom loans were made. The system will divide that amount by the number of applicants to whom loans were made (as reported in row A of the table in Section B, Item 1 above to calculate the average income.

A	B	C
Sum of Incomes	Number of Applicants to Whom Loans Were Made	Average Gross Annual Income
$	System-generated	System-generated

3. In the table below, enter the number of loans made to applicants who reported incomes in each of the specified ranges. The total number of loans should match the number you reported in row A of the table in Section B, Item 1 above. The system will calculate the percentage of loans made to individuals in each income category.

	Number and Percentage of Loans Made to Applicants with Incomes of						Total
	$15,000 or Less	$15,001 to $30,000	$30,001 to $45,000	$45,001 to $60,000	$60,001 to $75,000	$75,001 or More
Number of loans							System-generated
Percentage of loans	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated

(System will generate an error message if total number of loans does not match number reported in row A of the table in Section A.1.)

2. Loan Type

a) Enter the number of partnership loans by loan type. Any row left blank will automatically count the number of loans as zero. The system will calculate the percentage of loans that fall into each category. For guidance on how to categorize partnership loans, refer to the instructions. Report each loan in only one category.

Type of Loan	Number of Loans	Percentage of Loans
Revolving Loan - Low Interest (prime or less)		System-generated
Revolving Loan – Preferred Interest (greater than prime)		System-generated
Low interest (prime or less)
Without interest buy-down or loan guarantee		System-generated
Without interest buy-down only		System-generated
With loan guarantee only		System-generated
With both interest buy-down and loan guarantee		System-generated
Preferred interest (greater than prime)
Without interest buy-down or loan guarantee		System-generated
Without interest buy-down only		System-generated
With loan guarantee only		System-generated
With both interest buy-down and loan guarantee		System-generated
Total	System-generated	System-generated

(System will generate an error message if total number of loans does not match number reported in row A of the table in Section A.1.)

b) Enter the dollar value of both partnership loans and revolving loans. The number of loans in each category will automatically populate based on the table in 3(a). Report each loan in only one category.

Type of Loan	Number of Loans	Dollar Value of Loans
Revolving loans	System-generated	$
Partnership loans	System-generated	$
Total	System-generated	System-generated

3. Interest Rates

a) Enter the lowest and highest interest rates among all loans made, including both revolving and partnership loans. For interest buy-downs, report the interest rate to which you bought the loan down:

Lowest: ______________%

Highest: ______________%

b) Use the table below to calculate the average interest rate for all loans, including both revolving and partnership loans. Enter the sum of interest rates for all loans in Column A. The system will divide that amount by the number of loans made as previously reported and automatically populated in row A to calculate the average interest rate.

A	B	C
Sum of Interest Rates	Number of Loans Made	Average Interest Rate
	System-generated	System-generated

c) In the table below, enter the number of loans made at interest rates in each of the specified ranges. The total number of loans should match the number you reported in row A of the table in Section A.1. above.

Number of Loans Made at Interest Rates of --								Total Number of Loans
0-2.0%	2.1–4.0%	4.1–6.0%	6.1–8.0%	8.1-10%	10.1-12%	12.1-14%	14+%
								System-generated

(System will generate an error message if total number of loans does not match number automatically populated as the total based on previous reported data.)

4. Types and Dollar Amounts of AT Financed

Use the table below to provide information on the types of devices or services financed and the dollar value of loans made for each type of device or service. Report devices/services only once in a category per loan. For guidance on how to classify devices and services, and decision rules for devices and services that could be classified in more than one way, refer to the General Instructions. Because a single loan may pay for more than one device or service, the number of devices and services reported in this table may exceed the number of loans. However, the total dollar value of loans should be the same as reported previously in 3.b.

For large building access projects or similar activities with multiple devices in one AT category, the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ramping of a house would be a home modification). Where an AT service (such as an evaluation) was part of a financial loan, include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go in the “hearing” category).

If the loan is a refinance, and the AT purchased with previous loan has never been reported, you should reported the AT devices/services purchased with the previous loan as the AT associated with the refinance. (NOTE: If the refinance is of a previous loan and the AT purchased with the previous loan has been reported, the refinance should not be reported at all.).

Type of AT Device/Service	Number of Devices Financed	Dollar Value of Loans
Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Total	System-generated	$ System-generated

(System will generate an error message if total dollar value of loans does not match amount reported in the Total Dollar Value of Revolving Loans and Partnership Loans calculated in Item 3(b) above.)

6. Defaults

In the first cell below, enter the number of loans that were in default during this reporting period. A loan is in default after 120 days in which the borrower has not made the scheduled payment for the balance still owed; or at which time the organization administering the loan paid the lending institution the remaining agreed upon balance of loan. Do not count any payments that may have been made by the loan administering organization on behalf of the borrower during that 120-day period as payments made by the borrower. (Rescue payments do not count as borrower payments and the 120 day clock continues).

In the second cell below enter the net dollar loss on defaulted loans. Net dollar loss on loans means the amount lost as a result of default during this reporting period after subtracting any funds that were recovered. It includes the amount that is unpaid on any loans in default and any loan guarantee payout amounts minus the amount of collateral recovered.

Number of Loans in Default	Net Dollar Loss on Loans

Note: If you have a loan in default for this reporting period and you reasonably believe you will be able to recoup some of the net dollar loss associated with this default during the next reporting period you can choose to defer reporting the default and the net dollar loss until the next reporting period. This should only occur when loans went into default later in the current reporting period and you have not had sufficient time to sell or otherwise recoup some of the value of the collateral.

7. Additional Data for Title III funded AFP

This section collects additional data ONLY for financial loans that are part of a Title III funded Alternative Financing Program (AFP). By completing this section you will NOT need to submit these loans in the separate AFP Progress Report.

a) Range of Dollar Amounts of Loans Provided

In the table below, enter how many loans were made within the range of dollar amounts shown below. This is the dollar amount of the entire loan, not the dollar amount divided among different devices if more than one device was purchased.

	Number and Percentage of Loans Made to Applicants in the Amount of
	$1,000 or Less	$1,001 to $5,000	$5,001 to $10,000	$10,001 to $15,000	$15,001 to $20,000	$20,001 to $25,000	$25,001 to $50,000	$50,001 or More	Total
Number of loans									System-generated
Percent of Loans	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated

(System will generate an error message if total number of loans does not match number reported in row A of the table in Section A.1.)

b) Highest and Lowest Loan Amounts

Enter the highest and lowest actual dollar amounts of loans provided during this reporting period:

Highest $_________

Lowest $ _________

c) Classification of Consumers Receiving Assistance

Use the tables below to report data about the consumers who received loans from your Title III funded alternative financing program (AFP) during this reporting period. The data should be provided only for the direct user of the AT, not the individual to whom the loan was provided (in some cases these are the same person, but often they are not).

A direct user is an individual that uses an AT Device or Service that provides a direct benefit or impact to the individual. A secondary user or beneficiary is a person who benefits from the user having an AT Device or Service. For example, if a family acquired a modified van for two children that are wheelchair users, both children would be considered direct users, but the parents of the children would be considered the secondary users or beneficiaries. Although a secondary user or beneficiary may benefit from the direct user having an AT device or service, for the data below, you must report on the direct user only.

i) Gender

Enter the total number of direct users of AT benefiting from a loan for a device or service by gender - female or male. If multiple persons are direct users of the AT provided by a single loan, the gender for each direct user should be reported.

Gender of Direct User(s)	Number
Female
Male
Total	System-generated

(Total must be equal to or greater than Row A of the table in Section A.1 – total loans made.)

ii) Age

Enter the total number of direct users of AT benefiting from a loan for a device or service by the age range distribution. If multiple persons are direct users of the AT provided by a single loan, the age for each direct user should be reported. Programs should report the actual age of the direct user(s) at the time the loan was made.

Age of Direct Users of AT	Number
0-9
10-17
18-29
30-39
40-49
50-59
60-69
70-79
80+
Total	System-generated

(Total must equal total in i. above.)

iii) Type of Disability

In this section, report on the AT user’s abilities affected by the AT they are purchasing during this reporting period. An AT user may be affected in more than one area, therefore the data reported for each user may reflect multiple areas or “Type of Abilities” affected.

Type of Ability	Number
Seeing
Hearing
Talking/communicating
Getting around/mobility
Handling objects, reaching
Learning new information
Remembering
Interacting with others/socializing
Total	System-generated

(Total must be equal to or greater than i. and ii. The number of areas affected may exceed the totals reported for age and gender.)

2. State Financing Activities that Provide Consumers with resources and services that result in the acquisition of AT devices and services

1. Overview of Activities Performed

How many other state financing activities that provide consumers with access to funds for the purchase of AT devices and services were included in your approved State Plan? – enter number. Which of the following best describes this state financing activity? Drop-down box: (1)“last resort” activity; (2) telecommunications distribution; (3) other (specify)

2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and Services and Number for whom Performance Measure Data are Collected

In this table, report the number of individuals who acquired AT devices and services through this activity, by the Rural Urban Continuum Code (RUCC) for the county in which they reside. For guidance on how to find a county’s RUCC, please see the “General Instructions.”

Of the recipients of AT devices and service, identify the number for whom performance measure data can be reported. This may be all of the recipients or may be fewer if the Statewide AT Program is administering a program (using external funding to purchase/provide the AT) on behalf of an entity that has responsibility for providing AT devices and services. The performance measure data questions are not answerable by such entities. While the number of individuals served by such programs should be reported here and in #3 below, performance measure data should not be collected for those individuals.

County of Residence	Individuals Served
A.Metro (RUCC 1-3)
B.Non-Metro (RUCC 4-9)
C. Total Served	i System-generated
D. Excluded from Performance Measure (Number of individuals excluded from performance measure data collection because AT is provided to or on behalf of an entity that has an obligation to provide the AT such as schools under IDEA or VR agencies/clients)	Mandatory explanation
E. Number of Individuals Included in Performance Measures	ii System-generated

(ii = i minus excluded number D)

If a number is reported in D you must provide a description of the reason the individuals are excluded from the performance measure: _________________________________________

3. Types and Dollar Amounts of AT Funded

Use the table below to provide information on the number of devices or services funded and the amount of funding provided, by type of AT device/service. Report each device or service in only one category. For guidance on how to classify devices and services, and decision rules for devices and services that could be classified in more than one way, refer to the General Instructions.

For large building access projects, the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ramping of a house would each be one home modification). Where funding was provided for an AT service (such as an evaluation), include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go in the “hearing” category).

Type of AT Device/Service	Number of Devices Funded	Value of AT Provided
Vision		$
Hearing		$
Speech communication		$
Learning, cognition, and developmental		$
Mobility, seating and positioning equipment		$
Daily living		$
Environmental adaptations		$
Vehicle modification and transportation		$
Computers and related		$
Recreation, sports, and leisure		$
Total	System-generated	$ System-generated

3. State Financing Activities that Allow Consumers to Obtain AT at Reduced Cost

1. Overview of Activities Performed

How many activities that allow consumers to obtain AT at reduced cost were included in your approved State Plan? – enter number. Which of the following best describes this state financing activity? Drop-down box: (1) cooperative buying activity; (2) other (specify)

2. Geographic Distribution and Number of Individuals Served

In this table, report the number of individuals who acquired AT devices and services through this activity, by the Rural Urban Continuum Code (RUCC) for the county in which they reside. For guidance on how to find a county’s RUCC, please see the “General Instructions.”

Of the recipients of AT devices and service, identify the number for whom performance measure data can be reported. This may be all of the recipients or may be fewer if the recipients of the cost savings are entities that have responsibility for providing AT devices and services regardless of cost. The performance measure data questions are not answerable by such entities. While the number of individuals served by such programs should be reported here and in #3 below, performance measure data should not be collected for those individuals. See the instructions “Who To Collect Data” for more information.

County of Residence	Number of Individuals Served
A.Metro (RUCC 1-3)
B.Non-Metro (RUCC 4-9)
C. Total Served	i System-generated
D. Excluded from Performance Measure (Number of individuals excluded from performance measure data collection because AT is provided to or on behalf of an entity that has an obligation to provide the AT such as schools under IDEA or VR agencies/clients)	Mandatory explanation
E. Number of Individuals Included in Performance Measures	ii System-generated

(ii = i minus excluded number D.)

If a number is reported in D you must provide a description of the reason the individuals are excluded from the performance measure: _________________________________________

3. Savings to Consumers, by Type of AT Device/Service

Use the table below to provide information on the number of devices or services provided to consumers and the savings to consumers resulting from this activity, by type of AT device or service. Report each device or service in only one category. For guidance on how to classify devices and services, and decision rules for devices and services that could be classified in more than one way, refer to the General Instructions.

For each type of AT device, enter the total estimated current purchase price of the devices and the total amount for which devices were sold. The system will calculate the resulting savings to consumers. Use the Manufacturer’s Suggested Retail Price (MSRP) to determine the current purchase price of the device. If you are unable to find the exact price for a particular item, use the value of a comparable device. Using estimates is acceptable when exact pricing is not available. You may need to identify multiple similar devices and average to estimate a MSRP. If the device was given away, use a sale price of zero in your calculations.

For large building access projects, the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ramping of a house would each be one home modification). Where funding was provided for an AT service (such as an evaluation), include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go in the “hearing” category).

Type of AT Device/Service	Number Provided	Total Estimated Current Retail Purchase Price	Total Price for Which Devices Were Sold	Savings to Consumers
Vision				System-generated
Hearing				System-generated
Speech communication				System-generated
Learning, cognition, and developmental				System-generated
Mobility, seating and positioning				System-generated
Daily living				System-generated
Environmental adaptations				System-generated
Vehicle modification and transportation				System-generated
Computers and related				System-generated
Recreation, sports, and leisure				System-generated
Total	System-generated	System-generated	System-generated	System-generated

4. Anecdote

Provide at least ONE anecdote about an individual who benefited from a state financing activity. Do not provide more than TWO anecdotes. If you have a picture to accompany the narrative you submit, please check the box provided. If you reported Title III AFP financial loan data in section A, you MUST provide an anecdote here for that activity. You may provide an additional anecdote if you reported an activity in section B and/or C. Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

If you have a picture to accompany anecdote #1, please check here

(Narrative item #1)

If you have a picture to accompany anecdote #2, please check here

(Narrative item #2)

5. Performance Measures

State financing activities are covered by the Acquisition Performance Measure. To collect data for this measure, statewide AT programs will collect follow-up information from consumers. Use data collected from consumers to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/service are needed.

The total number of customers from whom data is reported must equal the sum of the number of individuals to whom financial loans were made (as reported in Section A.1.A) and the number of individuals served by other state financing activities who are included in performance measures (as reported in Sections B.2.E.ii and C.2.E.ii).

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Could only afford the AT through the statewide AT program (n,d)
2. AT was only available through the statewide AT program (n,d)
3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d)
4. Subtotal	System-generated	System-generated	System-generated
5. None of the above (d)
6. Subtotal	System-generated	System-generated	System-generated
7. Nonrespondent (d)
8. Total	System-generated	System-generated	System-generated	System-generated
9. Performance on this measure	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Non-respondents are included in denominator. (System will generate an error message if total reported in column at far right does not equal total of Sections A.1.A plus B.2.E.ii plus C.2.E.ii )

6. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by state financing activities.

Customer Rating of Services	Number of Customers	Percent
Highly satisfied		System-generated
Satisfied		System-generated
Satisfied somewhat		System-generated
Not at all satisfied		System-generated
Nonrespondent		System-generated
Total	System-generated
Response rate	System-generated

(System will generate an error message if total does not equal total reported in Sections A.1.A plus B.2.C.i plus C.2.C.i.)

G. Notes

Describe any unique issues that may affect your data in this section (e.g., types of devices/services that may not be financed because they are financed by other programs).

(Narrative item)

Reuse

Outline

Overview of Activities Performed

1. Number of recipients of reused devices

2. Device exchange activities

3. Device Reassignment/Refurbishment and Repair Activities

4. Open-ended loans

5. Anecdote

6. Performance measures

7. Customer satisfaction

8. Notes

Section 4f requirement: the number, type, estimated value, and scope of assistive technology devices exchanged, repaired, recycled, or reutilized (including redistributed through device sales, loans, rentals, or donations) through the device reutilization activities, and an analysis of the individuals with disabilities that have benefited from the device reutilization activities

Device reuse includes device exchange activities and device reassignment/refurbishment and repair activities. It also includes open-ended device loans in which the borrower can keep the device for as long as it is needed, because these loans are considered a form of “acquisition.”

Device exchange activities are those in which devices are listed in a “want ad”-type posting and consumers can contact and arrange to obtain the device (either by purchasing it or obtaining it for free) from the current owner. Exchange activities do not involve warehousing inventory and do not include sanitation or refurbishing of used devices. In some cases, a Statewide AT Program serves as an intermediary directly involved in making this exchange; in others the consumer and current owner make this exchange without the involvement of the Statewide AT Program. Data on device exchange may be difficult to gather if your program does not serve as an intermediary directly involved in the exchange.

Device reassignment/refurbishment and repair activities are those in which devices are accepted (usually by donation) into an inventory; are sanitized and/or refurbished as needed; and then offered for sale, loan, rental, or give away to consumers as redistributed products. Repair activities are those in which device(s) are repaired for an individual (without the ownership of the device changing hands) which prevent the owner from needing to purchase a device.

Open-ended device loans are when a device borrower can keep a device (usually a reused device) for as long as required to meet a particular need. Open-ended device loans are generally distinguishable from short-term device loans by the length of the typical loan period. Open-ended loans are generally long term with the device placed with a consumer on a permanent basis but done via loan rather than ownership transferring to the consumer.

Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting any device reuse activities? Check yes or leave unchecked.

A. Number of Recipients of Reused Devices

In this table, report the number of recipients of devices through device exchange, reassignment/refurbishment and repair activities, and open-ended loans. In the table below, report on the number of individuals who receive devices through a reuse program. Recipients should be reported only once, even if they receive multiple devices during this reporting period. (The multiple devices will be reported in subsequent sections.) There are two reasons that individuals may be excluded from the Performance Measures –

1. Given the fact that many device exchange programs have little direct contact with device buyers, it may not be possible to collect information sufficient to include these individuals in the performance measures. Therefore, you can choose to exclude exchange device recipients from performance measure data reporting simply because you are unable to or it is too difficult to collect such data. Exchange is the only activity that offers this opt-out option for performance measure data.

2. Some entities that have an obligation to provide AT may provide it via reuse. For example, a school has an obligation to provide AT devices identified in an IEP and the school may obtain the device through the reuse program. In this case, the performance measure questions are not answerable by the school because the issues of affordability or availability are not allowable reasons to limit access to AT that has been identified as necessary by the IEP team. You should exclude from the performance measures device recipients who acquire reused devices under these circumstances.

Activity	Number of Individuals Receiving a Device from Activity
A. Device exchange
B. Reassignment/refurbishment and Repair
C. Open-ended loans
D. Total Served	i System-generated
Performance Measure
E. Device Exchange - Excluded from Performance Measure
F. Reassignment/refurbishment and Repair and Open-ended loans – Excluded from Performance Measure because AT is provided to or on behalf of an entity that has an obligation to provide the AT such as schools under IDEA or VR agencies/clients)	Mandatory explanation
G. Number of Individuals Included in Performance Measures	ii System-generated

(ii = i minus sum of excluded numbers, E + F)

If a number is reported in F you must provide a description of the reason the individuals are excluded from the performance measure: _________________________________________

B. Device Exchange Activities

Enter the total number of devices exchanged (listed by one individual/entity and obtained by another) during the reporting period, by AT type. For each type of AT device, enter the total estimated current purchase price of the devices and the total amount for which the devices were exchanged. To report a device as “exchanged” you must have documentation of the price for which it was sold or exchanged. Use the Manufacturer’s Suggested Retail Price (MSRP) to determine the current purchase price of the device. If you are unable to find the exact price for a particular item, use the value of a comparable device. You many need to identify multiple similar products and average to identify a MSRP. Using estimates is acceptable when exact pricing information is not available. If the device was given away, use a sale price of zero in your calculations. The system will calculate the resulting savings to consumers in the last column.

Type of AT Device	Number of Devices Exchanged	Total Estimated Current Purchase Price	Total Price for Which Device(s) Were Exchanged	Savings to Consumers
Vision				System-generated
Hearing				System-generated
Speech communication				System-generated
Learning, cognition & developmental				System-generated
Mobility, seating and positioning				System-generated
Daily living				System-generated
Environmental adaptations				System-generated
Vehicle modification & transportation				System-generated
Computers and related				System-generated
Recreation, sports and leisure				System-generated
Total	System-generated	System-generated	System-generated	System-generated

C. Device Reassignment/Refurbishment and Repair Activities

Enter the total number of devices reassigned/refurbished/repaired and acquired by an end user during the reporting period, by type. For each type of AT device acquired, enter the total estimated current purchase price of the devices and the total price for which the devices were sold. The system will calculate the resulting savings to consumers. Use the MSRP to determine the current purchase price of the device. If you are unable to find the exact price for a particular item, use the value of a comparable device. You many need to identify multiple similar products and average to identify a MSRP. Using estimates is acceptable when exact pricing information is not available. If the device was given away, use a sale price of zero in your calculations.

Type of AT Device	Number of Devices Reassigned/ Refurbished & Repaired	Total Estimated Current Purchase Price	Total Price for Which Devices Were Sold	Savings to Consumers
Vision				System-generated
Hearing				System-generated
Speech communication				System-generated
Learning, cognition and developmental				System-generated
Mobility, seating & positioning				System-generated
Daily living				System-generated
Environmental adaptations				System-generated
Vehicle modification & transportation				System-generated
Computers and related				System-generated
Recreation, sports and leisure				System-generated
Total	System-generated	System-generated	System-generated	System-generated

D. Open Ended Loans

Enter the total number of devices loaned in open-ended loans during the reporting period, by type. For each AT type, enter the total estimated current purchase price of the devices and the cost to the consumer for the loan. If there was no charge to the consumer, use a zero as the cost to the consumer. The system will calculate the resulting savings to consumers. Use the MSRP as the current purchase price of the device. If you are unable to find the exact MSRP for an item, use a comparable device price. You may need to identify multiple similar products and average for the MSRP. Using estimates is acceptable when exact pricing information is not available. NOTE: Open-ended loans are reported only once in the reporting period the loan is made; not in subsequent years even if the loan is still open.

Type of AT Device	Number of Devices on Long-Term Loan	Total Estimated Current Purchase Price	Cost to Consumer for the Loan	Savings to Consumers
Vision				System-generated
Hearing				System-generated
Speech communication				System-generated
Learning, cognition and developmental				System-generated
Mobility, seating and positioning				System-generated
Daily living				System-generated
Environmental adaptations				System-generated
Vehicle modification & transportation				System-generated
Computers and related				System-generated
Recreation, sports and leisure				System-generated
Total	System-generated	System-generated	System-generated	System-generated

E. Anecdote

Provide ONE anecdote about an individual who benefited from a reuse activity. For guidance on information to include in the anecdote, please see the “General Instructions.” If you have a picture to accompany the narrative you submit, please check the box provided. Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

If you have a picture to accompany anecdote #1, please check here

(Narrative item #1)

F. Performance Measures

Device reuse activities are covered by the Acquisition Performance Measure. To report data for this measure, statewide AT programs will collect follow-up information from consumers to complete the tables below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed.

Performance measure for exchange, reassignment/refurbishment and repair and open-ended device loan activities should be reported in the table below. The number of customers reported should equal the total number reported in (ii) of Section A.

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Could only afford the AT through the statewide AT program (n,d)
2. AT was only available through the statewide AT program (n,d)
3. AT was available through other programs, but the system was too complex or wait time was too long (n,d)
4. Subtotal	System-generated	System-generated	System-generated
5. None of the above (d)
6. Subtotal	System-generated	System-generated	System-generated
7. Nonrespondent (d)
8. Total	System-generated	System-generated	System-generated	System-generated
9. Performance on this measure	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Nonrespondents are included in the denominator for calculation of performance. (System will generate an error message if total reported in column at far right does not equal total of Sections A.ii )

G. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by device reuse activities.

Customer Rating of Services	Number of Customers	Percent
Highly satisfied		System-generated
Satisfied		System-generated
Satisfied somewhat		System-generated
Not at all satisfied		System-generated
Nonrespondent		System-generated
Total surveyed	System-generated
Response rate	System-generated

(System will generate an error message if total surveyed is not equal to the number of individuals who acquired a reused device reported in Section A(i).

H. Notes

Describe any unique issues that may affect your data in this section. If you have a device exchange program, please describe your data collection method, any challenges with collecting these data, and plans for overcoming those challenges.

(Narrative item)

Device Loans

Outline

Overview of Activities Performed

1. Short-Term Device Loans by Type of Purpose

2. Number of Device Loans by Type of Borrower

3. Length of short-term device loans

4. Types of devices loaned

5. Anecdote

6. Performance measures

7. Customer satisfaction

8. Notes

Section 4f requirement: the number, type, and length of time of loans of assistive technology devices provided to individuals with disabilities, employers, public agencies, or public accommodations through the device loan program…and an analysis of individuals with disabilities who have benefited from the device loan program

Statewide AT programs provide short-term loans of AT devices to individuals or entities. The purpose of the loan may be to assist in decision making, to serve as a loaner while the consumer is waiting for device repair or funding, to provide an accommodation on a short-term basis for a time-limited event, for training, self-education or other professional development activities. Loans for the purpose of decision-making should be included in the access performance measure. Loans for all other purposes: providing a device during repair or while waiting for funding, providing an accommodation for a time-limited event, and training or personnel development should be included in the acquisition performance measure.

In this section, report only on short-term loans in which devices are borrowed for a limited or prescribed amount of time for one of the four purposes described in Section A. Based on national data, typical short-term loan periods range from between 30 and 45 calendar days. Device loans for significantly longer periods should be reviewed as possible open-ended loans, especially when the loan structure is done as an alternative to device ownership transferring to the consumer. Open-ended device loans, in which the device borrower can keep the device for as long as it is needed, should be reported under “Device Reuse.”

Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting short-term device loans? check yes or leave unchecked.

1. Short-Term Device Loans by Type of Purpose

In this section, report the total number of short-term device loans made during the reporting period. A loan (counted as one) is defined as an occasion on which a device or devices were borrowed by an individual/entity who will use the device for one of the following purposes –

1) To make a decision (one decision) based on data, judgments, and other relevant information gained from trial use of the device in a natural environment with technical assistance available, upon request, from someone who has technical expertise related to the device(s) borrowed.

2) To provide loaner equipment during device repair or while waiting for funding (no decision is involved).

3) To provide an accommodation for a time-limited event such as a meeting or situation such as a hospital stay (no decision is involved). Device loans that provide access to education, employment, or community living for as long as the individual has the device out on loan should be reported as an open-ended loan.

4) To conduct training, self-education, or other professional development activities (no decision involved).

The number of short-term device loans will equal the number of borrowers reported in B, as each loan will be classified by the type of individual or entity that borrows. The number of loans will NOT necessarily equal the number of devices borrowed as reported in D as there may be multiple devices borrowed within a single loan.

Use the following guidelines to determine the number of short-term device loans made:

If the same individual or entity borrows devices on more than one occasion during the reporting period, count each occasion as a separate loan if a separate decision will be made

If the same individual or entity borrows devices on more than one occasion during the reporting period and a single decision will be made, count that as one device loan.

If you extend the period of a short-term device loan, count that as a separate loan only if (1) the extension is for a different purpose than the original loan and a separate decision will be made; or (2) the borrower is an “intermediary” borrowing on behalf of others (e.g., a teacher), and the intermediary is requesting an extension to accommodate a second “end user” (i.e., an individual other than the one for whom the loan was initially made) and a second decision will be made.

Report the number of short-term device loans made by primary purpose of the loan. Count each loan in only one category, even if the loan included multiple devices. If at least one device included in the loan was obtained for the purpose of decision-making, report the loan in the first row.

Primary Purpose of Short-Term Device Loan	Number of Loans
Assist in decision making (device trial or evaluation)	Access Performance Measure
Serve as loaner during device repair or while waiting for funding	Acquisition Performance Measure
Provide an accommodation on a short-term basis for a time-limited event/situation	Acquisition Performance Measure
Conduct training, self-education or other professional development activity	Acquisition Performance Measure
Total	i. System-generated

2. Number of Device Loans by Type of Borrower

In this section, report the number of device loans by type of borrowers, by type of individual or entity. The total number of device borrowers should equal the total number of short-term device loans reported by primary purpose in Item A. You must be able to categorize borrowers to report them in this table as there is no option for “unable to categorize” or “other”.

Type of Individual or Entity	Number of Device Borrowers
Individuals with disabilities
Family members, guardians, and authorized representatives
Representatives of Education
Representatives of Employment
Representatives of Health, allied health, and rehabilitation
Representatives of Community Living
Representatives of Technology
Total	System-generated

3. Length of Short-Term Device Loans

What is the length of a short-term device loan, as established by your statewide AT program’s policies not including extensions? Please report the length in calendar days. If your policy/procedures establish a range, use the midpoint.

Length of short-term device loan, in days: (Numeric field)

4. Types of Devices Loaned

Enter the number of devices that were loaned, by type of device. For guidance on how to categorize devices, refer to the “General Instructions.” The number of devices loaned may exceed the number of loans reported above in Item A, since a loan may include more than one device.

Type of AT Device	Number
Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Total	System-generated

5. Anecdote

Provide ONE anecdote about an individual who benefited from a device loan activity. For guidance on information to include in the anecdote, please see the “General Instructions.” If you have a picture to accompany the narrative you submit, please check the box provided. Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

If you have a picture to accompany anecdote #1, please check here

(Narrative item #1)

6. Access Performance Measures

Device loan activities for a decision-making purpose are covered by the Access Performance Measure. To collect data for this measure, statewide AT programs will collect data from all customers who obtained device loans for the purpose of decision-making (i.e., the number reported in Item B. Row A). That data will be used to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed.

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Decided that an AT device/service will meet needs (n,d)
2. Decided that an AT device/service will not meet needs (n,d)
3. Subtotal	System-generated	System-generated	System-generated
4. Have not made a decision (d)
5. Subtotal	System-generated	System-generated	System-generated
6. Nonrespondent (d, if > 35%)
7. Total	System-generated	System-generated	System-generated	System-generated
8. Performance on this measure	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator.

Nonrespondents in excess of 35% are included in the denominator for calculation of performance.

(System will generate an error message if total reported in column on far right does not equal total reported in Item A, Row 1.).

G. Acquisition Performance Measures

Device loan activities for the purpose of providing loaner equipment during device repair or while waiting for funding, for providing an accommodation for a time-limited event, and for professional development activities are covered by the Acquisition Performance Measure. To report data for this measure, statewide AT programs will collect follow-up information from consumers to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed. The number of borrowers reported must equal the total number reported in rows 2, 3, and 4 of Section A.

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Could only afford to borrow the AT through the statewide AT program (n,d)
2. AT was only available through the statewide AT program (n,d)
3. AT was available to borrow from other programs, but the system was too complex or the wait time was too long (n,d)
4. Subtotal	System-generated	System-generated	System-generated
5. None of the above (d)
6. Subtotal	System-generated	System-generated	System-generated
7. Nonrespondent (d if > 35%)
8. Total	System-generated	System-generated	System-generated	System-generated
9. Performance on this measure	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Nonrespondents are included in the denominator for calculation of performance. (System will generate an error message if total reported in column at far right does not equal total of Sections A rows 2 + 3 + 4.)

H. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by device loans (total in A.i.)

Customer Rating of Services	Number of Customers	Percent
Highly satisfied		System-generated
Satisfied		System-generated
Satisfied somewhat		System-generated
Not at all satisfied		System-generated
Nonrespondent		System-generated
Total	System-generated
Response rate	System-generated

I. Notes

Describe any unique issues that may affect your data in this section (e.g., types of devices that are not loaned because those loans are available from another source, or types of devices that are not loaned because your inventory does not include those devices, difficulty obtaining data from intermediaries, etc.)

(Narrative item)

Device Demonstrations

Outline

Overview of Activities Performed

1. Number of Device Demonstrations by Device Type

2. Types of participants

3. Number of referrals

4. Anecdote

5. Performance measures

6. Customer satisfaction

7. Notes

Section 4f requirement: the number and type of device demonstrations and referrals provided and an analysis of individuals with disabilities who have benefited from the demonstrations and referrals

Device demonstrations compare the features and benefits of a particular AT device or category of devices for an individual or small group of individuals. The purpose of a device demonstration is to enable an individual to make an informed choice.

Whenever possible, the participant should be shown a variety of devices. Device demonstrations should not be confused with training activities at which devices are demonstrated. Training activities are instructional events designed to increase knowledge, skills, and competencies, generally for larger audiences. Training can also be targeted/focused instruction for an individual or small group (such as in-depth training for an individual consumer on a specific AT device). This targeted training is for skill development whereas device demonstrations are for decision-making purposes.

Device demonstrations also should not be confused with public awareness activities at which devices are demonstrated. The key difference is that device demonstrations are intended to enable an individual to make an informed choice rather than merely making him or her aware of a variety of AT.

In a device demonstration for an individual, guided experience with the device(s) is provided to the participant with the assistance of someone who has technical expertise related to the device(s). This expert may be in the same location as the participant or may assist the participant through Internet or distance learning mechanism that provides real-time, effective communication to deliver the necessary device exploration. (See the instructions for further clarification and examples.)

As noted in the instructions for this section, a device demonstration referral is provision of information about a specific source where the customer may obtain additional information or services related to AT. A referral must provide a consumer with information on how to contact that source directly. Referrals may be made to funding sources, service providers, vendors, or repair services. Do not include referrals to other components of your statewide AT program. Report only on referrals that result from demonstration activities, not referrals made through an information and assistance activities.

Overview of Activities Performed

Did your approved State Plan for this reporting period include conduct device demonstrations? Check yes or leave unchecked.

1. Number of Device Demonstrations by Device Type

In this section, report the number of device demonstrations by type of device/service demonstrated during this reporting period. For guidance on how to categorize devices and services, refer to the “General Instructions.” A device demonstration (counted as one) is defined as an occasion in which one or more devices within a category are demonstrated to an individual or small group who will make a decision (one decision) based on data, judgments, comparisons and other relevant information gained from the interaction with the equipment and demonstrator. The number of device demonstrations will NOT necessarily equal the number of demonstration participants reported in B as there may be multiple participants in a demonstration even though only one decision will be made.

Type of AT Device/Service	Number of Demonstrations of this Type of AT Device/Service
Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Total	System-generated

B. Types of Participants

In the table below, enter the number of individuals who participated in device demonstrations, by type of participant. Include all individuals participating in demonstrations, not just those who are making a decision (or for whom a decision is being made). For guidance on how to categorize participants, refer to the “General Instructions.” You must be able to categorize participants to report them in this table as there is no option for “unable to categorize” or “other”.

Type of Participant	Number of Participants in Device Demonstrations
Individuals with disabilities
Family members, guardians, and authorized representatives
Representatives of Education
Representatives of Employment
Representatives of Health, allied health, and rehabilitation
Representatives of Community Living
Representatives of Technology
Total	System-generated

C. Number of Referrals

In this section, report the number of referrals made to each type of entity. Since participants in a demonstration may receive more than one referral, or may not be referred at all, the number of referrals may be greater or less than the number of participants and number of demonstrations. Do not include referrals to other components of your statewide AT program.

Type of Entity	Number of Referrals
Funding source (non-AT program)
Service provider
Vendor
Repair service
Others

D. Anecdote

Provide ONE anecdote about an individual who benefited from a device demonstration activity. For guidance on information to include in the anecdote, see “General Instructions.” If you have a picture to accompany the narrative you submit, please check the box provided. Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

If you have a picture to accompany anecdote #1, please check here

(Narrative item #1)

E. Performance Measures

Device demonstrations are covered by the Performance Measure 1 (access). To collect data for this measure, statewide AT programs will collect data from the identified decision-maker who participated in demonstrations (one per demonstration as reported in Item A). That data will be used to complete the table below. Refer to the “General Instructions” for guidance on how to categorize the primary purpose for which AT devices/services are needed.

Response	Primary Purpose for Which AT is Needed
	Education	Employment	Community Living	Total
1. Decided that an AT device/service will meet needs (n,d)
2. Decided that an AT device/service will not meet needs (n,d)
3. Subtotal	System-generated	System-generated	System-generated
4. Have not made a decision (d)
5. Subtotal	System-generated	System-generated	System-generated
6. Nonrespondent (d)
7. Total	System-generated	System-generated	System-generated	System-generated
8. Performance on this measure	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator. Non-respondents are included in the denominator for calculation of performance. (System will generate an error message if total reported in column on far right does not equal total reported in Section A.)

F. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by device demonstration.

Customer Rating of Services	Number of Customers	Percent
Highly satisfied		System-generated
Satisfied		System-generated
Satisfied somewhat		System-generated
Not satisfied		System-generated
Nonrespondent		System-generated
Total	System-generated
Response rate	System-generated

(System will generate an error message if total does not equal total reported in Section B.)

G. Notes

Describe any unique issues that may affect your data in this section (e.g., types of participants that may appear to be underrepresented because they receive demonstration services from another organization, types of devices/services that are not demonstrated because those demonstrations are available from another source, issues related to use of distance education mechanisms to deliver demonstrations, or issues related to dissatisfaction (e.g.; consumer may be dissatisfied because they assumed the AT Program could purchase the device for them)

(Narrative item)

Overall Acquisition Performance Measure (auto-populated)

The acquisition performance measure is the sum of State Financing, Reuse and Short-term Device Loan (purposes of providing device during repair, while waiting for funding and short-term accommodation) performance measure data.

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Could only afford the AT through the statewide AT program	System-generated	System-generated	System-generated	System-generated
2. AT was only available through the statewide AT program	System-generated	System-generated	System-generated	System-generated
3. AT was available through other programs, but the system was too complex or the wait time was too long	System-generated	System-generated	System-generated	System-generated
4. Subtotal	System-generated	System-generated	System-generated	System-generated
5. None of the above	System-generated	System-generated	System-generated	System-generated
6. Subtotal	System-generated	System-generated	System-generated	System-generated
7. Nonrespondent	System-generated	System-generated	System-generated	System-generated
8. Total	System-generated	System-generated	System-generated	System-generated
9. Performance on this measure	System-generated	System-generated	System-generated	System-generated
10. RSA Performance Target
11. Met or Not Met

Overall Access Performance Measure (auto-populated)

The access performance measure is the sum of Short-term Device Loan (decision-making purposes) and Device Demonstration performance measure data.

Response	Primary Purpose for Which At is Needed			Total
	Education	Employment	Community Living
1. Decided that an AT device/service will meet needs	System-generated	System-generated	System-generated	System-generated
2. Decided that an AT device/service will not meet needs	System-generated	System-generated	System-generated	System-generated
3. Subtotal	System-generated	System-generated	System-generated	System-generated
4. Have not made a decision	System-generated	System-generated	System-generated	System-generated
5. Subtotal	System-generated	System-generated	System-generated	System-generated
6. Nonrespondent	System-generated	System-generated	System-generated	System-generated
7. Total	System-generated	System-generated	System-generated	System-generated
8. Performance on this measure	System-generated	System-generated	System-generated	System-generated
9. RSA Performance Target
10. Met/Not Met

Training

Outline

Overview of Activities Performed

1. Training participants: Number and types of participants; geographical distribution

2. Training topics

3. Description of training activities

4. Notes

Section 4f requirements: Training

1. “the number and general characteristics of individuals who participated in training…(such as individuals with disabilities, parents, educators, employers, providers of employment services, health care workers, counselors, other service providers, or vendors)”

2. ”the topics of such training”

3. “to the extent practicable, the geographic distribution of individuals who participated in the training.”

Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that statewide AT programs provide training and technical assistance to assist students with disabilities who receive transition services under IDEA and adults with disabilities maintaining or transitioning to community living. Section e also requires that at least 5% of the money spent on State Leadership activities be used for transition activities.

The AT Act of 1998, as amended provides a combined description of training and technical assistance (see Section-Specific Definitions). Following is guidance on what activities to report in this section and how to distinguish training activities from public awareness or technical assistance activities. Report each activity only once, in the appropriate section.

This section of the reporting form also collects information on training activities that are related to transition. Information on technical assistance activities related to transition should be reported in that section of the form. Reminder- each Statewide AT Program must report on at least one transition activity related to school transition (e.g., secondary school to post-school) AND one transition activity related to community living transition (e.g. congregate living to community living). The activity reported may be either a training event or a technical assistance initiative.

Training activities are instructional events, usually planned in advance for a specific purpose or audiences, which are designed to increase participants’ knowledge, skills, and competencies regarding AT. Such events can be delivered to large or small groups, in-person, or via telecommunications or other distance education mechanisms. In general, participants in training can be individually identified and could complete an evaluation of the training. Examples of training include classes, workshops, and presentations that have a goal of increasing skills, knowledge, and competency, as opposed to training intended only to increase general awareness of AT.

Distinguishing Training Activities from Public Awareness Activities

Training activities have more depth and breadth than public awareness activities and are focused on skill building and competency development. If the purpose of a training session is to create awareness, the training session should be counted under public awareness, not under training. In general, participants in training can be individually identified, while in awareness activities, it may not be possible to identify each individually.

Working with individual consumers on how to use a particular AT device or troubleshooting problems with devices should be reported under Public Awareness as “Information and Assistance.”

Distinguishing Training from Technical Assistance

Training is designed to teach, present, or guide individuals in order to impart knowledge, skills, and competencies. Technical assistance is focused on providing extensive assistance to state or local agencies or other entities (rather than individuals) and generally involves problem solving to achieve a mutually agreed-upon goal. Technical assistance may involve multiple contacts and interactions over an extended period of time.

In some cases, training may be a component of technical assistance. Training that is provided as part of technical assistance can be reported here, but only if the training was one of several technical assistance activities. If training was the only technical assistance activity, it can be reported as either training or technical assistance, but not both.

Overview of Activities Performed

Training activities are required and must be reported as described below.

1. Training Participants: Number and Types of Participants; Geographical Distribution

1. Enter the number of training participants by type. The participant may self-determine the appropriate descriptor for themselves or such information may be derived from other training event records. Use “unable to categorize” when no data can be obtained on type of participant.

Type of Participant	Number
Individuals with disabilities
Family members, guardians, and authorized representatives
Representative of Education
Representative of Employment.
Representative of Health, allied health, and rehabilitation
Representative of Community Living
Representative of Technology
Unable to Categorize
Total

2. Enter the number of individuals who participated in training, by the Rural Urban Continuum Code (RUCC) of the participant’s county. For a consumer, you determine the RUCC by the county in which he or she resides. For a representative, you determine the RUCC by the county in which they generally provide services. Training participants for whom you cannot determine a county are counted in “Unknown.” For additional guidance on the RUCC, refer to the “General Instructions.”

Metro (RUCC 1-3)	Non Metro (RUCC 4-9)	Unknown	TOTAL

The Total in A(2) above must equal the Total of A(1)

2. Training Topics

Enter the number of participants by the primary purpose of the training.

Training topics are organized into categories:

1. AT products and services, which includes subcategories of AT types.

2. AT funding, policy and practice, which includes subcategories of common topics in this category and space other related AT topics.

3. Information Technology/Telecommunications which includes subcategories of related uses of information technology and telecommunications products. For participants in this training topic, you will need to collect a performance measure, see Data Collection Instrument IT/Telecommunication Training Performance Measure.

4. Combination of AT products and services, AT funding, policy and practice and/or IT/Telecommunications. (Use this category only when absolutely necessary.)

5. Transition, including transition from school to work or postsecondary education and transition to community living. (Use this category for ALL transition activities even if they could be reported as AT Products/Services, AT Funding/Policy, etc.)

Primary Topic of Training	Number of Training Participants
AT Products/Services Training focused on AT: such as instruction to increase skills and competency in using AT, and integrating AT into different settings
2.AT Funding/Policy/ Practice Training focused on funding sources and related laws, policies, and procedures required to implement and deliver access to AT devices/services and related.
3.Information Technology/Telecommunication Access Training focused on accessible information technology and telecommunications including web access, software accessibility, procurement of accessible IT and telecommunications, etc.	A performance measure must be collected for these training participants
4 Combination of any/all of the above -- AT Products/Services, AT Funding/ Policy/Practice and/or IT/Telecommunications Access
5.Transition Training focused on education transition (school to work or post-secondary education and early intervention (birth to 3) to school aged (3 -21) and community transition (maintaining or transitioning to community living). (Note: A number must be reported here unless transition technical assistance activity/activities are reported.)
Total	System generated

The Total Number of Training Participants must equal the Total in A(1) and A(2).

3. Description of Training Activities

In Item 1 below, describe an innovative or high-impact training activity that is not related to transition. In Item 2 below, describe a training activity that is related to transition.

1. Briefly describe one innovative or high-impact training activity conducted during this reporting period. Note who conducted the training (e.g., type of expertise of staff) and characteristics of the audience (including number that attended). In one sentence, describe the topic, content, and/or approach of the training. In one sentence, summarize the positive result or intended impact of the training. Do not include overall descriptions of conferences held, unless the conference had a unique purpose/outcome.

Narrative item- Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

2. Briefly describe a training activity related to transition conducted during this reporting period. Note who conducted the training (e.g., type of expertise of staff) and characteristics of the audience (including number that attended). In one sentence, describe the topic, content, and/or approach of the training. In one sentence, summarize the positive result or intended impact of the training. Do not include overall descriptions of conferences held, unless the conference had a unique purpose and outcome. This section must be completed unless you are reporting transition technical assistance activities. If this section is completed, an associated number of training participants must be reported in Section B Row 5.

Narrative item- Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

D. IT/Telecommunications Training Performance Measure

Outcome/result from IT/Telecommunication Training Received	Number
IT and telecommunications procurement or development policies, procedures, or practices will be improved or better implemented to ensure accessibility.(n,d)
Training or technical assistance will be developed or implemented to ensure accessibility of IT and telecommunications. (n,d)
No known outcome at this time. (d)
Nonrespondent (d)
TOTAL (must equal number reported in Section B.3)	System-generated
Performance Measure Percentage	System-generated
RSA Target Percentage
Met/Not Met

E. Notes

Describe any unique issues that may affect the data in this section, (e.g., reasons why particular topics or audiences were emphasized or were not included during this reporting period).

(Narrative item)

Technical Assistance

Outline

Overview of Activities Performed

1. Frequency and nature of technical assistance

2. Description of technical assistance activities

3. Notes

Section 4f requirements:

Technical Assistance

“The frequency of provision and nature of technical assistance provided to State and local agencies and other entities.”

Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that AT programs provide training and technical assistance to assist students with disabilities who receive transition services under IDEA and adults with disabilities maintaining or transitioning to community living. Section e also requires that at least 5% of the money spent on State Leadership activities be used for transition activities.

The AT Act of 1998, as amended provides a combined description of training and technical assistance (see “General Definitions”). Additional descriptions of technical assistance activities are provided below, along with guidance for distinguishing technical assistance activities from public awareness activities and training activities.

Technical Assistance (TA) is defined as direct problem-solving service provided by Statewide AT Program staff to assist programs and agencies in improving their services, management, policies, and/or outcomes. TA may be provided in person, by electronic media such as telephone, video, or e-mail, and by other means. The following are examples of technical assistance: needs assessment, program planning or development, curriculum or materials development, administrative or management consultation, program evaluation and site reviews of external organizations, and policy development.

Mandatory transition activities that are technical assistance are reported in this section; mandatory transition activities that are training are reported in the training section. Reminder- each Statewide AT Program must report on at least one transition activity related to school transition (e.g., secondary school to post-school) AND one transition activity related to community living (e.g. maintaining or transitioning to community living). The activity reported may be either a training event or a technical assistance initiative.

Distinguishing Technical Assistance from Information & Assistance

Technical assistance is provided to agencies or other organizations, not to individuals. Intensive support provided to an individual, for example assisting an individual troubleshoot problems with an AT device or address a funding issue, is reported under information and assistance. Technical assistance typically includes multiple contacts/interactions over an extended period of time with an agency or organization. Less intensive support services, including single-contact requests for information or limited assistance from agencies or organizations should also be reported under information and assistance.

Distinguishing Technical Assistance from Training

Training is designed to teach, present, or guide individuals in order to impart knowledge, skills, and competencies to individuals, while technical assistance may be designed to help entities (not individuals) improve their policies, practices, and procedures and generally involve problem solving.

In some cases, training may be a component of technical assistance. Training that is provided as part of technical assistance can be reported in the training section, but only if the training was one of several technical assistance activities. If training was the only technical assistance activity, it can be reported as either training or technical assistance, but not both.

Overview of Activities Performed

Technical Assistance activities are required and all activities should be reported in the aggregate in Section A. One Technical Assistance activity must be described in Section B and a transition Technical Assistance activity must be reported unless a transition training activity was reported.

A. Frequency and Nature of Technical Assistance

Complete this section summarizing all major technical assistance activities that you conducted. Indicate the percentage of total technical assistance provided by the type of program or agency receiving the technical assistance. Use the person hours invested in each technical assistance activity to report the percentage by type of program or agency. For example, if you conducted two major TA activities this reporting period with 90 total person hours for an activity related to education and 50 person hours for an activity related to employment, you would report 64% in education and 36% in Employment.

Program or agency receiving technical assistance	Percentage of all TA
Education
Employment
Health, Allied Health, Rehabilitation
Community Living
Technology (Information Technology, Telecommunications, Assistive Technology)
Total	Must equal 100%

B. Description of Technical Assistance Activities

In Item 1 below, describe an innovative or high-impact technical assistance activity that is not related to transition. For this item, choose a technical assistance activity that had an outcome. In Item 2 below, describe a technical assistance activity that is related to transition. The transition technical assistance activity is not required to have an outcome.

1. Describe in detail one innovative or high-impact technical assistance activity conducted during this reporting period. Note who provided the technical assistance (e.g., type of expertise of staff) and characteristics of the recipient agency. In two sentences: (1) describe the topic, content, and/or approach of the technical assistance; and (2) summarize the positive result or impact of the technical assistance.

Narrative item- Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

2. Briefly describe one technical assistance activity related to transition conducted during this reporting period. Note who provided the technical assistance (e.g., type of expertise of staff) and characteristics of the recipient agency. In two sentences: (1) describe the topic, content, and/or approach of the technical assistance; and (2) summarize the positive result or impact of the technical assistance. NOTE: This section must be completed unless a transition training activity is reported.

Narrative item- Each narrative is limited to 1000 words for purposes of the MIS data system. While you can enter words past this limit, they will not be displayed when data is pulled from MIS.

C. Notes

Describe any unique issues with data in this section (e.g., reasons why particular topics or audiences were emphasized or were not included during this reporting period).

(Narrative item)

Public Awareness and Information and Assistance

Outline

Overview of Activities Performed

1. Public awareness activities

2. Information and Assistance

3. Notes

Section 4f requirement: “the number of individuals assisted through the public awareness activities and statewide information and referral system”.

Public awareness activities are designed to reach large numbers of people, including activities such as public service announcements, radio talk’s shows and news reports, newspaper stories and columns, newsletters, brochures, and public forums. Actual numbers of information recipients are often difficult to know for certain, but should be reported when known, and in other cases estimated as accurately as possible. Public awareness activities should be reported, as accurately as possible, in Part A of this section.

Information and assistance includes provision of information and supports to individuals and provision of referrals to other entities. All of these activities may be provided in person, over the telephone, via email, or other effective communication mechanisms.

Distinguishing Information and Assistance from Device Demonstration Referral

In this section, report only on referrals resulting from information dissemination activities, such as calls to a 1-800 number or e-mails. Referrals resulting from device demonstrations should be reported under device demonstrations.

Distinguishing Public Awareness from Training

The intended outcome of an activity should determine whether it is reported under public awareness or training. Include presentations made for the purpose of general awareness under public awareness. Do not include training sessions with the intended outcome of participants applying new knowledge or skills in addressing AT device/service issues (which should be reported under training).

Overview of Activities Performed

Public awareness and information and assistance activities are required and must be reported.

1. Public Awareness Activities

In this section report on public awareness activities intended to reach a wide audience. In the table below enter the known or estimated number of individuals reached during the reporting period by each type of public awareness activity. Activities must be reported in one of the categories provided (there is no “other” category). The categories provided should enable reported of all major public awareness activities. Presentations reported in this section are for the purpose of general awareness. Training sessions with the intended outcome of participants applying new knowledge or skills in addressing AT device/service issues should be reported as a training activity. (NOTE: Purchasing promotional items is not allowable under OMB Circular direction and as such should not be reported in this section.)

Public Awareness Activity	Estimated Number of Individuals Reached
Newsletters
Other print materials
Listservs/blogs/social media
Internet information
Other electronic media
PSA - radio/TV/other media
Presentations/expos/conferences
Total

2. Information and Assistance

Information and assistance (I&A) activities are those in which the AT program responds to requests for information and/or puts individuals in contact with other agencies, organizations, or companies that can provide them with needed information on AT products, devices, services, or funding sources or provides intensive assistance to individuals about AT products, devices, services, or funding sources. This information may be provided in person, over the telephone, via email, or by some other communication mechanism.

In the table below report the number of individuals to whom you provided information and assistance services by type of individual or entity (see instructions for classification system explanation) and by the content of the information and assistance provided. To the extent practicable each unique request for information and assistance should be counted only once. For the content of the I&A provided, differentiate between –

• Information and assistance about specific AT products, devices, or services, or selecting an AT product, device, or service; and

• Information and assistance that addresses obtaining funding for or otherwise acquiring AT devices and services or providing AT policy/practice information

Types of Recipients of Information and Assistance	AT Device/ Service	AT Funding/ Policy/Practice	Total
Individuals with disabilities			System-generated
Family members, guardians, and authorized representatives			System-generated
Representative of Education			System-generated
Representative of Employment			System-generated
Representative of Health, Allied Health, and Rehabilitation			System-generated
Representative of Community Living			System-generated
Representative of Technology			System-generated
Unable to Categorize			System-generated
Total	System-generated	System-generated	System-generated

3. Notes

Describe any unique issues with your data in this section.

(Narrative item)

State Improvement Outcomes

Outline

Overview of Activities Performed

1. State improvement outcomes

2. State improvement outcome (if second one reported)

It is understood and expected that AT Programs will coordinate and collaborate with other public and private entities in terms of receiving referrals, sharing information, serving on advisory board, etc. and will provide technical assistance to a variety of agencies and entities throughout the reporting period. Outcomes of state improvements initiatives must result in policy, practice or procedure improvements beyond those associated with or already reported in previous state-level and state leadership coordination and collaboration sections.

Section 4f requirements: “the outcomes of any improvement initiatives carried out by the State as a result of activities funded under this section, including a description of any written policies, practices, and procedures that the State has developed and implemented regarding access to, provision of, and funding for, assistive technology devices, and assistive technology services, in the contexts of education, health care, employment, community living, and information technology and telecommunications, including e-government.”

Overview of Activities Performed

State improvement outcomes are not required. You may report up to two MAJOR state improvement outcomes for this reporting period. How many will you be reporting? (For example, you may have worked with your state Information Technology Office to implement an Executive Order related to web accessibility or may have worked with your Medicaid office to streamline procedures for obtaining wheeled mobility devices.) -- enter zero, 1 or 2

1. State Improvement Outcomes

Complete this section for the first MAJOR state improvement outcome to be reported.

1. In one or two sentences, describe the outcome. Be as specific as possible about exactly what changed during this reporting period as a result of the AT program’s initiative. (Narrative field)

2. In one or two sentences, describe the written policies, practices, and procedures that have been developed and implemented as a result of the AT program’s initiative. Include information about how to obtain the full documents, such as a Web site address or e-mail address of a contact person, but do not include the full documents here. (If there are no written policies, practices, and procedures, explain why.) (Narrative field)

3. What was the primary area of impact for this state improvement outcome? Drop-down box: Education – Employment -- Health, Allied Health, Rehabilitation -- Community Living -- Technology (Information Technology, Telecommunications, and Assistive Technology).

B State Improvement Outcome

If you have a second MAJOR outcome to report, this section will need to be completed with items 1 through 3 above.

Additional and Leveraged Funds

Outline

Overview of Activities Performed

1. Leveraged Funding for State Plan Activities (Previously Reported)

2. Leveraged Funding for Activities Not in State Plan (not previously reported)

3. Notes

Section 4f requirement: “(x) the source of leveraged funding or other contributed resources, including resources provided through subcontracts or other collaborative resource-sharing agreements, from and with public and private entities to carry out State activities described in subsection (e)(3)(B)(iii), the number of individuals served with the contributed resources for which information is not reported under clauses (i) through (ix) or clause (xi) or (xii), and other outcomes accomplished as a result of such activities carried out with the contributed resources”

Overview of Activities Performed

Did you have Additional and Leveraged Funding to report? (Check yes or leave unchecked).

In this section, provide information on funding that has been leveraged to support statewide AT Program activities. Report only actual dollars leveraged; do NOT report in-kind contributions. The additional and leveraged funding reported in this section is NOT necessarily considered program income under federal guidelines.

1. Leveraged Funding for State Plan Activities (Previously Reported)

Statewide AT Programs often establish partnerships and leverage funds to support state implementation of required AT Act activities as described in your State Plan. These funds should be reported by entering the sources and amounts of non-AT Act funds that you received during this reporting period to support your State Plan activities. Report each source and amount in the reporting period that it was received, even if not all of the funds were expended in that reporting period. Do not report AFP endowments or matching funds. Identify which state level or leadership activity the funds were allocated to support. If funds were received to support more than one activity, report an amount for each activity according to funding allocations. The number of individuals served by those funds or other outcomes should have already been reported in the appropriate previous sections.

Fund Source (select one)	Amount	Use of Funds (select one)
Ο Federal Ο Public/State Agency Ο State Appropriations Ο Private		Ο State Financing Ο Training Ο Reuse Ο Technical Assistance Ο Demonstration Ο Public Awareness, I&A Ο Device Loan
option to repeat row data

B. Leveraged Funding for Activities Not in State Plan (data not previously reported in other activity sections)

Statewide AT Programs may also leverage funds to support activities that are authorized by the AT Act but not included in a State Plan. For example, a state may administer external funding for an activity that could be reported as Other State Financing, but they choose not to include that data in the State Financing section. If an activity is approved as part of your state plan and has associated leveraged funding, it should NOT be reported here but should be reported in the previous section A. This section is limited to only non-State Plan approved activities with leveraged funding that do not have information on individuals served or other outcome data reported in previous sections.

Funds used to support these activities should be reported by entering the sources and amounts of non-AT Act funds that you received during this reporting period. Report each source and amount in the reporting period that it was received, even if not all of the funds were expended in that reporting period. Do not report AFP endowments or matching funds. Identify which activities those funds were allocated to support. Report the number of individuals served by each funding source identified; or describe other outcomes if the “individuals served” is not an appropriate outcome measure.

Fund Source	Amount	Use of Funds – select one	Individuals Served or Other Outcome
Ο Federal Ο Public/State Agency Ο State Appropriations Ο Private		Ο State Financing Ο Reuse Ο Demonstration Ο Device Loan Ο Training Ο Technical Assistance Ο Public Awareness, I&A	(enter the number individuals served or describe the outcome)
option to repeat row data

C. Notes

Describe any unique issues with your data in this section (e.g., the reason why you were unable to report the number of individuals served with additional or leveraged funds).

(Narrative item)

Data Collection Instrument
Access Performance Measure

TO BE COMPLETED BY PROGRAM STAFF ID (optional) ____________

 Services provided:

Device demonstration

OR

Device loan (decision-making purpose)

 Date service delivery was completed: __________

 Date this form was received: ____________________

Please answer the following questions about the services you received from the (insert name of statewide AT program or its subcontractor). We need this information to provide high quality services and to meet the requirements for receiving federal funding.

1. The primary purpose for which I need (or the person I represent needs) an AT device or service is related to:

(Please mark only one answer.)

Education—participating in any type of educational program

Community living—carrying out daily activities, participating in community activities, using community services, or living independently

Employment—finding or keeping a job; getting a better job; or participating in an employment training program, vocational rehabilitation program, or other program related to employment

2. What kind of decision about AT devices or services were you (or someone you represent) able to make after your device demonstration or device loan?

(Please mark only one answer.)

_____ Decided that an AT device or service will meet my needs (or the needs of someone I represent).

_____ Decided that an AT device or service will not meet my needs (or the needs of someone I represent).

_____ Have not made a decision.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.

Data Collection Instrument
Acquisition Performance Measure (SFA and Reuse)

TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________

 Services provided:

“State financing” services—including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and services at reduced cost or free, or other related services

Device reuse— received an AT device through a device exchange, reassignment/refurbish or repair or open-ended loan program

 Date service delivery was completed: __________

 Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of statewide AT program or its subcontractor). We need this information to provide high-quality services and to meet the requirements for receiving federal funding.

1. The primary purpose for which I need (or the person I represent needs) an AT device or service is related to:

(Please mark only one answer.)

Education—participating in any type of educational program

Community living—carrying out daily activities, participating in community activities, using community services, or living independently

Employment—finding or keeping a job; getting a better job; participating in an employment training program, vocational rehabilitation program, or other program related to employment

2. Why did you chose to obtain an AT device/service from our program?

(Please mark only one answer.)

_____ I could only afford the AT through this program. (I could not afford it through other programs.)

_____ The AT was only available to me through this program. (I am not eligible or don't qualify for other programs, the AT is not covered by other funding sources or the specific device I needed is not provided by other programs.)

_____ The AT was available to me through other programs, but the system was too complex or the wait time was too long.

_____ None of the above

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.

Data Collection Instrument
Acquisition Performance Measure (Device Loan)

TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________

 Short-term device loan purposes:

Providing loaner equipment during device repair or while waiting for funding

Providing an accommodation for a time-limited event

Conducting training, self-education or other professional development activity

 Date service delivery was completed: __________

 Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of statewide AT program or its subcontractor). We need this information to provide high-quality services and to meet the requirements for receiving federal funding.

1. The primary purpose for which I need (or the person I represent needs) an AT device or service is related to:

(Please mark only one answer.)

Education—participating in any type of educational program

Community living—carrying out daily activities, participating in community activities, using community services, or living independently

Employment—finding or keeping a job; getting a better job; participating in an employment training program, vocational rehabilitation program, or other program related to employment

2. Why did you chose to borrow an AT device/service from our program?

(Please mark only one answer.)

_____ I could only afford to borrow the AT through this program. (I could not afford to rent or borrow it through other programs.)

_____ The AT was only available to me through this program. (I am not eligible or there is no other rental or device loan program available; or the specific device I needed is not loaned by other programs.)

_____ The AT was available to borrow from other programs, but the system was too complex or the wait time was too long. (I couldn’t borrow the device in a timely manner.)

_____ None of the above

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.

Data Collection Instrument
IT/Telecommunications Training Performance Measure

TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________

 IT/Telecom Training Session

 Date training was provided: __________

 Date this form was received: ____________________

Please answer the following question about the training you participated in provided by (insert name of statewide AT program or its subcontractor). We need this information to provide high-quality services and to meet the requirements for receiving federal funding.

What do you anticipate will be the primary outcome of your participation in this training on Information Technology/Telecommunications Access?

(Please mark only one answer that best represents the primary outcome.)

_____ IT and telecommunications (web, software, etc.) procurement or development policies, procedures, or practices will be improved or better implemented to ensure accessibility

_____ Training will be developed/implemented to ensure accessibility of websites, software or other IT and telecommunications (web, software, etc.)

_____ Outcome is unknown at this time.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.

Survey Instrument
Customer Satisfaction

TO BE COMPLETED BY AT PROGRAM STAFF ID (optional) __________

 Services provided:

Device demonstration

Device loan

“State financing” services—including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and services at reduced cost or free, or other related services

Device reuse— received an AT device through a device exchange, reassignment/refurbish or repair or open-ended loan program

 Date service delivery was completed: __________

 Date this form was received: ____________________

1. Which of the following best reflects your level of satisfaction with the services you received?

(Check one.)

_____ Highly satisfied

_____ Satisfied

_____ Satisfied somewhat

_____ Not at all satisfied

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820-0572. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.