Access Performance Measure 

TO BE COMPLETED BY PROGRAM STAFF

 ID (optional) ____________

 Services provided:

 Device demonstration

 OR

 Device loan

 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

 Information technology/telecommunications—using computers, software, Web sites, 

telephones, office equipment, and media

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. 

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 5 minutes 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 AT 

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. 
Acquisition Performance Measure 

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 exchange—received an AT device through a device exchange program

 Device recycling—received an AT device through a device recycling program

 OR

 Open-ended loan – received an AT device through an open-ended loan

 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

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 5 minutes 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 AT 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.