Administration for Community Living 

State Grants for Assistive Technology Program 

Annual Progress Report (AT APR) 

OMB # 0985-0042 

Expires: 10/31/2020 

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 404 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, applicable to Section 4 formula funded grantees for 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 Robert Groenendaal, Administration for Community Living, 330 C Street, SW, Washington, 

DC 20201. 

This document was prepared by the Center for Assistive Technology Act Data Assistance under

Grant No. 90AN0001-01-00 by the U.S. Department of Health and Human Services. 

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Table of Contents 

General Information........................................................................................................................ 3 

State Financing................................................................................................................................ 4 

Reuse............................................................................................................................................. 14 

Device Loans ................................................................................................................................ 19 

Device Demonstrations................................................................................................................. 24 

Overall Performance Measures..................................................................................................... 28 

Training ......................................................................................................................................... 29 

Technical Assistance..................................................................................................................... 34 

Public Awareness and Information and Assistance ...................................................................... 37 

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 ICT Accessibility 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 (APR) for State Grants for Assistive Technology.” 

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General Information 

Statewide AT Program (Information to be listed in national State AT Program Directory) 

1. State Program Title 

2. State AT Program URL (home page for State AT Program) 

3. Mailing address 5. State 

4. City 6. Zip code 

7. Main email address (for general public to use to contact State AT Program) 

8. Main phone number (for general public to use to contact State AT Program) 

9. Separate TTY number (for general public to use to contact State AT Program if applicable) 

Lead Agency 

10. Agency name 

11. Mailing address 13. State 

12. City 14. Zip code 

15. Lead Agency URL 

Implementing Entity 

16. Does your Lead Agency contract with an Implementing Entity to carry out the Statewide AT Program 

on its behalf? Yes No If yes, complete Items 17–22. 

17. Name of implementing entity 

18. Mailing address 20. State 

19. City 21. Zip code 

22. Implementing Entity URL 

Program director and other contacts 

23. Program Director for State AT Program (last, first) 

24. Title 

25. Phone 

26. E-mail 

27. Primary Contact at the Lead Agency (last, first) 

28. Title 

29. Phone 

30. E-mail 

31. Primary Contact at Implementing Entity (last, first) – If applicable 

32. Title 

33. Phone 

34. E-mail 

Person Responsible for completing this form if other than State AT Program Director 

34. Name (last, first) 

35. Title 

36. Phone 

37. E-mail 

Certifying Representative 

38. Name (last, first) 

39. Title 

40. Phone 

41. E-mail 

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State Financing 

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 for 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. 

A. Financial Loan Programs 

Did your approved State Plan include conducting a financial loan program? Check yes or 

leave unchecked. 

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State Financing 

1. Loan Applications 

In this section, report on both revolving loans and partnership loans. Revolving loans are 

made directly by the Statewide AT Program. Partnership loans 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 report 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 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 

A. Approved—loan made Systemgenerated 

B. 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) 

Systemgenerated 

C. Rejected Systemgenerated 

D. Total Systemgenerated Systemgenerated Systemgenerated 

2. 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 above). 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. 

a. Enter the lowest and highest income reported among all applicants to whom loans were 

made during the reporting period: 

Lowest: $______________ 

Highest: $______________ 

b. 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 above to calculate 

the average income. 

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State Financing 

A B C 

Sum of Incomes 

Number of Applicants to Whom Loans

Were Made 

Average Gross

Annual Income 

$ System-generated System-generated 

c. 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 first table. 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 

Systemgenerated 

Percentage 

of loans 

Systemgenerated Systemgenerated Systemgenerated Systemgenerated Systemgenerated Systemgenerated Systemgenerated 

(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.) ? 

3. 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 Loans System-generated 

Partnership Loans 

Without interest buy-down or loan guarantee System-generated 

With 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 

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State Financing 

4. 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.) 

5. 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, 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 report 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.) 

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Number of Loans in Default Net Dollar Loss on Loans 

 

 

 

 

State Financing 

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. 

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. 

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 

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: 

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State Financing 

(1)“last resort” activity; (2) telecommunications equipment distribution program (including 

deaf/blind EDP); (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 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 $ 

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State Financing 

Environmental adaptations $ 

Vehicle modification and transportation $ 

Computers and related $ 

Recreation, sports, and leisure $ 

Total System-generated $ System-generated 

C. 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 program; (2) AT leasing program; (3) AT 

fabrication program; (4) 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 Must Provide Performance Measure 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 

Page 10 
 

 

 

 

 

 

(Narrative item #2) 

Impact area:  Education  Employment  Community Living 

State Financing 

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 Systemgenerated 

System-generated System-generated System-generated 

D. 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. Each narrative is limited to 1800 

characters. Please check the area (education, employment, or community living) of the 

outcome/impact of the anecdote. 

If you have a picture to accompany anecdote #1, please add here with alt text. 

Page 11 

(Narrative item #1) 

Impact area:  Education  Employment  Community Living 
 

 

 

 

 

 

State Financing 

If you have a picture to accompany anecdote #2, please add it here with alt text. 

E. 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 Systemgenerated 

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 ) 

F. 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 

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State Financing 

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) 

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Reuse 

Outline 

Overview of Activities Performed 

A. Number of recipients of reused devices 

B. Device exchange activities 

C. Device Reassignment/Refurbishment and Repair Activities 

D. Open-ended loans 

E. Anecdote 

F. Performance measures 

G. Customer satisfaction 

H. 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 other cases 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 sanitation/refurbishment/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. 

Devices in a reuse inventory can be reassigned on a permanent basis to a new “owner” or 

provided as an open-ended loan to a borrower 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 an ongoing 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. 

Page 14 
 

 

 

 

 

 

 

 

 

Reuse 

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. 

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. Device Refurbish/Repair – Reassign and/or Open-Ended Loan 

C. Total Served i System-generated 

Performance Measure 

D. Device Exchange - Excluded from Performance Measure 

E. 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 

F. Number of Individuals Included in Performance Measures ii System-generated 

(ii = i minus excluded number E) 

If a number is reported in E. 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 may need to identify multiple similar 

products and average to identify a MSRP. Using estimates is acceptable when exact pricing 

Page 15 
 

 

 

 

 

 

 

 

 

 

Reuse 

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 Systemgenerated System-generated System-generated System-generated 

C. Device Refurbish/Repair - Reassignment and/or Open-ended Loan Activities 

Enter the total number of devices sanitized/refurbished/repaired and acquired by an end user 

through reassignment or open-ended loan during the reporting period, by type. (Please 

remember that multiple devices within the same AT category grouped together for a function 

should be reported as one device. For each type of AT device acquired, enter the total estimated 

current purchase price of the device and total price for which the devices were sold. The system 

will calculate the savings to consumers. Use the MSRP for the current purchase price of the 

device. If you are unable to find the exact price for an item, use the value of a comparable 

device. You may need to identify multiple similar products and average for an MSRP. Using 

estimates is acceptable when exact pricing is not available. If the device was given away, use a 

sale price of zero in your calculations. 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 

Sanitized/Repaired

/Refurbished 

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 

Page 16 
 

 

(Narrative item) 

Impact area:  Education  Employment  Community Living 

 

 

 

 

 

 

Reuse 

D. 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 1800 characters. Please check the area (education, employment, or 

community living) of the outcome/impact of the anecdote. 

If you have a picture to accompany the anecdote, please add it here. 

E. 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 

Education Employment Community Living Total 

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 Systemgenerated 

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 Section A.ii ) 

Page 17 
 

 

 

 

Reuse 

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 reuse activities. For exchange activities, you may 

collect and report satisfaction data from either the device seller or the device recipient in a 

completed exchange, but not both. 

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). 

G. 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) 

Page 18 
 

 

 

 

 

Device Loans 

Outline 

Overview of Activities Performed 

A. Short-Term Device Loans by Type of Purpose 

B. Number of Device Loans by Type of Borrower 

C. Length of short-term device loans 

D. Types of devices loaned 

E. Anecdote 

F. Performance measures 

G. Customer satisfaction 

H. 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. 

A. 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. 

Page 19 
 

 

 

 

 

 

 

Device Loans 

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 

B. 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 

Page 20 
 

 

 

 

Device Loans 

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 

C. 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) 

D. 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 

E. 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 

Page 21 
(Narrative item) 

Impact area:  Education  Employment  Community Living 

If you have a picture to accompany the anecdote, please add it here. 

 

 

 

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 Systemgenerated 

8. Performance on this System-generated System-generated System-generated 

measure 

 

 

Device Loans 

narrative is limited to 1800 characters. Please check the area (education, employment, or 

community living) of the outcome/impact of the anecdote. 

F. 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 access 

performance measure data from all customers who obtained device loans for the purpose of 

decision-making (the number reported in the first row of the Item A Table). 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. 

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 

Page 22 
 

 

 

 

 

Device Loans 

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 

Education Employment Community Living Total 

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 Systemgenerated 

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 Section 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) 

Page 23 
 

 

 

 

 

 

 

 

 

Device Demonstrations 

Outline 

Overview of Activities Performed 

A. Number of Device Demonstrations by Device Type 

B. Types of participants 

C. Number of referrals 

D. Anecdote 

E. Performance measures 

F. Customer satisfaction 

G. 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 during 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. 

Page 24 
 

 

 

Device Demonstrations 

A. 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 

Page 25 
 

 

(Narrative item) 

Impact area:  Education  Employment  Community Living 

 

 

Device Demonstrations 

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 1800 characters. Please check the area (education, employment, or community living) 

of the outcome/impact of the anecdote. 

If you have a picture to accompany the anecdote, please add it here. 

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 Total 

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 Systemgenerated Systemgenerated Systemgenerated 

4. Have not made a decision (d) 

5. Subtotal Systemgenerated Systemgenerated Systemgenerated 

6. Nonrespondent (d) 

Page 26 
 

 

 

 

 

Device Demonstrations 

7. Total Systemgenerated Systemgenerated Systemgenerated Systemgenerated 

8. Performance on this measure Systemgenerated Systemgenerated Systemgenerated 

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) 

Page 27 
 

 

 

 

 

 

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 shortterm 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. ACL Performance Target 75% 75% 75% 75% 

11. Met or Not Met System-generated System-generated System-generated System-generated 

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. ACL Performance Target 70% 70% 70% 70% 

10. Met/Not Met System-generated System-generated System-generated System-generated 

Page 28 
 

 

 

 

Training 

Training 

Outline 

Overview of Activities Performed 

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

B. Training topics 

C. Description of training activities 

D. 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 classified as a public awareness activity. In 

general, participants in training can be individually identified, while in awareness activities, it 

may not be possible to identify each individually. 

Page 29 
 

 

 

 

Training 

Working with individual consumers on how to use a particular AT device or troubleshooting 

problems with devices should be reported under “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. 

A. 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) 

Page 30 
 

 

 

 

 

 

 

 

 

 

 

Training 

B. 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 Accessibility Training focused on 

accessible information and communication technology (ICT) including web access, 

software accessibility, procurement of accessible ICT, etc. For participants in this 

training topic, you will need to collect a performance measure, see Data Collection 

Instrument ICT Accessibility 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 

1. 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 Accessibility 

Training focused on accessible information and communication technology (ICT) 

including web access, software accessibility, procurement of accessible ICT, 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 is reported.) 

If a number is 

reported here, a 

description must 

be provided in 

C.2. below. 

Total System 

generated 

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

C. 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 

Page 31 
 

 

 

 

Training 

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 3000 characters. 

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 3000 characters. 

3. Briefly describe a training activity related to Information and Communication 

Technology (ICT) accessibility 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. This section must be completed if you have attendees 

reported in the ICT accessibility topic area in Section B Row 3. 

Narrative item- Each narrative is limited to 3000 characters. 

D. Information & Communication Technology (ICT) Accessibility Performance Measure 

Outcome/result from ICT Accessibility Training Received Number 

ICT accessibility 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 ICT. (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 70% 

Met/Not Met System-generated 

Page 32 
Training 

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) 

Page 33 
 

 

 

 

Technical Assistance 

Outline 

Overview of Activities Performed 

A. Frequency and nature of technical assistance 

B. Description of technical assistance activities 

C. 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. Remindereach 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. 

Page 34 
 

 

 

 

Technical 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. 

Page 35 
 

 

 

 

 

Technical Assistance 

Narrative item- Each narrative is limited to 3000 characters. . 

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 3000 characters. 

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) 

Page 36 
 

 

 

 

 

Public Awareness and Information and Assistance 

Outline 

Overview of Activities Performed 

A. Public awareness activities 

B. Information and Assistance 

C. 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. 

A. Public Awareness Activities 

In this section report on one or two high impact public awareness activities. This can 

include newsletters (paper or digital), listservs, blogs, social media, web based information, 

public service announcement via television, radio, online broadcasts, podcasts, internet 

streamed or live presentations, or many other mechanisms designed to disseminate 

awareness level information to a wide audience. Please remember that 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 as a public awareness activity.) 

Page 37 
 

 

 

 

 

 

Public Awareness and Information and Assistance 

Describe in detail at least one and no more than two innovative or high-impact public 

awareness activities conducted during this reporting period. Highlight the content/focus of 

the awareness information shared, the mechanism used to disseminate or communicate the 

awareness information, the numbers and/or types of individuals reached, and positive 

outcomes resulting from the activity. If quantitative numbers are available regarding the 

reach of the activity, please provide those; however, quantitative data is not required. 

(Narrative item) Each narrative is limited to 3000 characters. 

(Narrative item) Each narrative is limited to 3000 characters. 

B. 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 

Page 38 
 

Public Awareness and Information and Assistance 

C. Notes 

Describe any unique issues with your data in this section. 

(Narrative item) 

Page 39 
 

 

 

 

 

 

 

 

 

Data Collection Instrument 

State Improvement Outcomes 

Outline 

Overview of Activities Performed 

A. State improvement outcomes 

B. 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 

A. 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. 

Page 40 
 

 

 

 

 

 

 

 

 

 

Additional and Leveraged Funds 

Additional and Leveraged Funds 

Outline 

Overview of Activities Performed 

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

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

C. 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. 

A. 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 

Page 41 
 

 

 

 

 

 

 

 

 

 

 

 

 

Additional and Leveraged Funds 

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) 

Page 42 
 

 

 

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: 

_____ 

_____ 

_____ 

 

 

 

 

Data Collection Instrument 

__________ 

____________________ 

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 0985-0042. 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. Send comments regarding the burden estimate or any other aspect of 

this collection of information, including suggestions for reducing this burden to Robert Groenendaal, Administration for 

Community Living, 330 C Street, SW, Washington, DC 20201. 

Page 43 
 

Data Collection Instrument 

Acquisition Performance Measure (SFA and Reuse) 

TO BE COMPLETED BY PROGRAM STAFF 

Services provided: 

ID (optional) 

 

 

 

 

 

 

 

 __

__

__

__

__

__

_ 

_ 

 _

_____ 

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 0985-0042. 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. Send comments regarding the burden estimate or any other aspect of 

this collection of information, including suggestions for reducing this burden to Robert Groenendaal, Administration for 

Community Living, 330 C Street, SW, Washington, DC 20201. 

Data Collection Instrument 

____________ 

“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? 

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

programs.) 

(Please mark only one answer.) 

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 

Page 44 
 

 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 

 

 

 

 

 

 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 

 

 

 

 

Data Collection Instrument 

Data Collection Instrument 

Acquisition Performance Measure (Device Loan) 

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

Short-term device loan purposes: 

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 

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 0985-0042. 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. Send comments regarding the burden estimate or any other aspect of 

this collection of information, including suggestions for reducing this burden to Robert Groenendaal, Administration for 

Community Living, 330 C Street, SW, Washington, DC 20201. 

Page 45 
 

Data Collection Instrument 

Information and Communication Technology Accessibility 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 highquality 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 and Communication Technology (ICT) accessibility? 

_____ 

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 0985-0042. 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. Send comments regarding the burden estimate or any other aspect of 

this collection of information, including suggestions for reducing this burden to Robert Groenendaal, Administration for 

Community Living, 330 C Street, SW, Washington, DC 20201. 

Data Collection Instrument 

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

_____ ICT (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 ICT (web, software, etc.) 

Outcome is unknown at this time. 

Page 46 

 

 
 

Survey Instrument

Customer Satisfaction 

TO BE COMPLETED BY AT PROGRAM STAFF 

Services provided: 

ID (optional) __________ 

 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: 

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 0985-0042. 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. Send comments regarding the burden estimate or any other aspect of 

this collection of information, including suggestions for reducing this burden to Robert Groenendaal, Administration for 

Community Living, 330 C Street, SW, Washington, DC 20201. 

Survey Instrument Consumer Satisfaction 

__________ 

____________________ 

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 

Page 47