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Administration for Community Living

State Grants for Assistive Technology Program

Annual Progress Report (AT APR)

Data Collection Instrument

OMB # 0985-0042

Expires:

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 21st Century Assistive Technology Act 

(AT 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. 90ATTA0002 by the U.S. Department of Health and Human Services.
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This Information Collection (IC) contains data needed for completion of the State Grants for AT 

Program Annual Progress Report (AT APR). The AT APR IC is designed to provide the 

Administration for Community Living (ACL) with information necessary for program planning 

and reporting data on required state-level and state leadership activities to Congress, the 

Secretary of Health and Human Services and additional entities. The AT APR is organized by 

the state-level and state leadership activities outlined in the 21st Century Assistive Technology 

Act (AT Act of 1998, as Amended). State Lead agencies or Implementing Entities will report on 

these state-level and state leadership activities and will provide data required by Section 4(f) of 

the Act and other necessary information. Annual data and information from individual states 

will be available to the public once the information is complete, formally submitted, reviewed 

and published. 

Table of Contents

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

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

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

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

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

National Outcome Measures......................................................................................................... 28

Educational/Training Activities ................................................................................................... 30

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

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

Coordination/Collaboration and State Improvement Outcomes................................................... 40

Additional and Leveraged Funds.................................................................................................. 42

Data Collection Instrument Access Performance Measure .......................................................... 44

Data Collection Instrument Acquisition Performance Measure ................................................... 45

Data Collection Instrument ICT Accessibility Performance Measure ......................................... 47

Survey Instrument Customer Satisfaction .................................................................................... 48

Additional 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
State Financing

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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 that 

provides for the purchase, lease, or other acquisition of, or payment for AT including Statefinanced 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 

that result in the acquisition of AT devices and services. Programs that directly provide AT may 

be programs operated with funds that are earmarked for particular types of consumers (such as 

children), particular types of AT (such as home modification), or for individuals who meet 

certain income limitations. States may not use AT Act dollars to provide funds or devices 

directly to individuals. AT Act dollars may be used to administer a last resort fund comprised of 

non-AT Act dollars. 

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.
State Financing

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A. Financial Loan Programs

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

leave unchecked. 

1. Loan Applications

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

made directly by the financial loan program with funds from the loan fund account that are 

repaid directly back into that account. The entire loan is serviced by the financial loan program. 

Partnership loans use dollars from another source, usually a financial institution, in which the 

financial loan program has an investment through loan guarantee, agreement with the partner 

institution based on an investment deposit, interest or principal buy-down, or other financial or 

administrative role.

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 Instruction Manual. 

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 SystemgeneratedSystemgeneratedSystemgenerated

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: $______________
State Financing

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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. 

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

SystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

(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 loans by loan type as defined below. The system will calculate the 

percentage of loans that fall into each category. Report each loan in only one category.

Revolving loan fund (or revolving loan): A loan fund that uses Statewide AT Program funds 

for loans. The AT program directly provides the funds that are to be loaned out and retains full 

control over to whom and at what terms the funds are loaned. As loans are repaid, the money is 

lent out again to other AT consumers — that is, the same money “revolves” out to other 

borrowers as earlier borrowers return it to the program.

Partnership loan: A loan administered by and using dollars from a source other than the 

Statewide AT Program, usually a financial entity, for which the Statewide AT Program has a 

direct financial investment through interest or principal buy-down, loan guarantee, or agreement 

with a financial institution based on an investment deposit or other written agreement with 

documentation of the subsidy provided for loans made (e.g. the financial institution provides a 

prime or less interest rate without buy-down payment.)

Interest buy-down loan: A partnership loan in which AT program funds are used to buy down 

the interest rate of a loan. The AT program uses funds to reduce the interest rate that lending 

institutions offer to consumers for loans to purchase AT. The AT program pays the lending 

institution for a portion of the interest on the loan, resulting in lower interest payments for the 

consumer over the long term.
State Financing

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Loan guarantee: A partnership loan in which the Statewide AT Program guarantees that the 

loan to a consumer is secure and will be repaid, thus increasing the lender’s willingness to loan 

funds. 

Type of Loan Number 

of Loans

Percentage 

of Loans

Revolving Loans System-generated

Partnership Loans 

 Without interest buy-down or loan guarantee Mandatory Explanation 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.) 

If a number is reported under Partnership Loans without interest buy-down or loan guarantee you 

must have a written agreement with the partner organization and must describe the subsidy 

provided by these loans or other investment of the financial loan program in these loans. 

Verification that these loans are all low interest (prime or less) will provide the required subsidy 

documentation. If these loans are not low interest, other verification of the clear subsidy and 

investment of the financial loan program in these specific loans must be described. 

______________________________________________________________________________

b) Enter the dollar value of 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 only once. 

Type of Loan Number of Loans Dollar Value of Loans

Revolving loans System-generated $

Partnership loans System-generated $

Total System-generated System-generated

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.
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Number of Loans Made at Interest Rates of -- Total Number 

0-2.0% of Loans 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 each device/service in 

only one category. For guidance on how to classify devices and services, and decision rules for 

devices and services, refer to the Instruction Manual. 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.) 

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 
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during that 120-day period as payments made by the borrower. (Rescue payments do not count 

as borrower payments and the 120-day clock continues.)

In the second cell below, enter the net dollar loss on defaulted loans. Net dollar loss on 

loans means the amount lost as a result of default during this reporting period after subtracting 

any funds that were recovered. It includes the amount that is unpaid on any loans in default and 

any loan guarantee payout amounts minus the amount of collateral recovered. 

Number of Loans in Default Net Dollar Loss on Loans 

Note: If you have a loan in default for this reporting period and you reasonably believe you will 

be able to recoup some of the net dollar loss associated with this default during the next reporting 

period you can choose to defer reporting the default and the net dollar loss until the next 

reporting period. This should only occur when loans went into default later in the current 

reporting period and you have not had sufficient time to sell or otherwise recoup some of the 

value of the collateral. 

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: (1)

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

deaf/blind EDP); (3) lease-to-own program, (4) 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 Instruction Manual. 

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
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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. Because a single recipient may acquire more than one device or service, the 

number of devices and services reported in this table may exceed the number of recipients. Refer 

to the Instruction Manual for decision rules on how to classify devices and services. 

For large building access projects, the numbers reported should reflect a logical access 

grouping (e.g., a bathroom modification or exterior ramping of a house would each be one home 

modification). Where funding was provided for an AT service (such as an evaluation), include 

that dollar amount in the appropriate AT category associated with the service (e.g., an 

audiological evaluation would go in the “hearing” category). 

Type of AT Device/Service

Number of Devices 

Funded Value of AT Provided

Vision $

Hearing $

Speech communication $

Learning, cognition, and developmental $

Mobility, seating and positioning equipment $

Daily living $

Environmental adaptations $

Vehicle modification and transportation $

Computers and related $

Recreation, sports, and leisure $

Total System-generated $ System-generated

C. State Financing Activities that Allow Consumers to Obtain AT for a Reduced Cost

1. Overview of Activities Performed 

How many activities that allow consumers to obtain AT for a 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 for savings program; 

(3) AT fabrication or AT maker 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 Instruction Manual. 

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 
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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. Because a single recipient may 

acquire more than one device or service, the number of devices and services reported in this table 

may exceed the number of recipients. Refer to the Instruction Manual for decision rules on how 

to classify devices and services.

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. In the case of fabrication or AT maker programs you will use the retail price of a 

comparable product to that which is being fabricated/made. In some cases, 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). 
State Financing

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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. 

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 

Instruction Manual 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 

(Narrative item #1) 

Impact area:  Education  Employment  Community Living 

(Narrative item #2) 

Impact area:  Education  Employment  Community Living 
State Financing

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number of individual recipients of 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

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 refurbishment/repair activities in 

which the device can be reassigned or placed on open-ended loan where the borrower can keep 

the device for as long as it is needed. All of these types of reuse 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. 

To report all required device exchange data, a Statewide AT Program will need to be able to 

collect performance measure outcome data. If the device buyer and seller make the exchange 

transaction without any involvement of the Statewide AT Program it will challenging to 

accurately gather and report required performance measure data at the conclusion of the 

exchange. While an online exchange listing system may be able to automatically collect some 

data from the seller and/or device listing (category of AT), the State AT Program must be able to 

confirm the exchange transaction was completed, verify the final sale price of the device, and 

attempt to collect performance measure data directly from the buyer after the exchange 

transaction is complete. This will require direct interaction with the end recipient to verify the 

completed exchange data and request a response to the performance measure. If your exchange 

program does not provide a mechanism to directly interact with the end recipient of device 

exchange and collect this required data, you should not report this activity data in the Annual 

Progress Report.

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, open-ended loan, 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 new device.
Reuse

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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 and/or lack of a set short-term period that is known to be 

appropriate for the loan. Open-ended loans are generally longer term without a known 

appropriate end-date and/or the device placed with a consumer on an ongoing basis but without 

transferring ownership to the consumer. 

Devices produced as a result of AT “maker” or fabrication activities MAY be included in 

reutilization if the fabricated devices are provided as open-ended loans, with the expectation that 

the devices will be returned to the program’s inventory when no longer needed. In general, 

however, AT fabrication should be considered as an “other” type of state financing as devices 

fabricated are frequently made specifically for an individual. In any case, devices produced 

through maker or fabrication activities must be counted as only one acquisition unless the 

fabricated device is taken back into the inventory of the reuse program from the original 

recipient and provided to a new recipient. 

Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting any device reuse

activities? Check yes or leave unchecked. 

A. Number of Recipients of Reused Devices

In this table, report the number of recipients who receive devices through device exchange or 

refurbish/ repair (reassign and/or open-ended loans). Recipients should be reported only once, 

even if they receive multiple devices as part of a reuse event. Of the recipients reported, identify 

the number for whom performance measure data cannot be reported. 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

D. – 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

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: _________________________________________
Reuse

Page 16

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. Because a single recipient may acquire more 

than one device or service, the number of devices and services reported in this table may exceed 

the number of recipients. 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 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. Because a single 

recipient may acquire more than one device or service, the number of devices and services 

reported in this table may exceed the number of recipients. However, multiple devices within the 

same AT category grouped together for a function should be reported as one device (e.g. 

multiple components of a functional seating system). 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. 
Reuse

Page 17

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

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 Instruction Manual. 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 Instruction Manual 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

(Narrative item) 

Impact area:  Education  Employment  Community Living 
Reuse

Page 18

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 )

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 19

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 loan purpose 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 educational/training, 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, while waiting for funding, providing an 

accommodation for a time-limited event, and educational/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 even if multiple devices in the same AT category were 

borrowed) 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.
Device Loans

Page 20

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 an accommodation for 

a longer period of time should be carefully reviewed to ensure it is indeed a short-term loan 

and not more of an open-ended loan (reported in reuse) in which the borrower needs to use the 

device for a longer period of time.

4) To conduct educational/training activities, 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 event. A device loan event for decision-making 

is defined by the decision to be made. In general, the decision will be based on borrowing one or 

more devices within a single AT category in which the device loan event is reported. The same 

individual may borrow multiple vision devices at the same time or across time (borrow one 

device, return it, borrow another, return it) to make one overall decision which is one loan event 

with multiple devices and one decision outcome. Or the same individual can borrow multiple 

vision devices (same or across time) and the purpose is separate decisions (e.g. a provider is 

borrowing to make decisions on behalf of different beneficiaries which is multiple loan events.) 

It is critical to identify the purpose of the device loan first so that the loan event data can be 

structured to collect accurate data for that event. If a loan is extended it should not be counted as 

a separate loan unless the extension creates a new, separate loan event purpose. 

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 borrowed for decision-making, report the loan in the first row. 

Primary Purpose of Short-Term Device Loan Number of Loans

1. Assist in decision making (device trial or evaluation) Access Performance Measure

2. Serve as loaner during device repair or while waiting for funding Acquisition Performance Measure

3. Provide an accommodation on a short-term basis for a time-limited 

event/situation

Acquisition Performance Measure

4. Conduct education/training 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 - type of individual 

or entity by decision-making purpose and by all other purposes. For guidance on how to 

categorize borrowers, refer to the Instruction Manual. You must be able to categorize borrowers 

to report them in this table as there is no option for “unable to categorize” or “other”. 

The total number of device borrowers for decision-making purpose (total line i below) must 

equal Section A line 1 above. The total number of device borrowers for all other purposes (total 
Device Loans

Page 21

line ii below) must equal the sum of Section A lines 2, 3 and 4 above. The total number of 

device borrowers (total line iii below) must equal the total number of short-term device loans 

reported above in Section A. 

Type of Individual or Entity

Number of Borrowers

DecisionmakingAll other 

Purposes

Total

Individuals with disabilities System-generated

Family members, guardians, and authorized representatives System-generated

Representatives of Education System-generated

Representatives of Employment System-generated

Representatives of Health, allied health, and rehabilitation System-generated

Representatives of Community Living System-generated

Representatives of Technology System-generated

Total i. Systemgenerated

ii. Systemgeneratediii. Systemgenerated

C. Length of Short-Term Device Loans

Enter the standard length of loan established by your AT Program policies/procedures not 

including extensions. Please report the length in calendar days. If your policy/procedures 

establish a range, use the midpoint. Please note this is NOT actual days, it is your policy period. 

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

D. Types of Devices Loaned

Enter the number of devices that were loaned by device type for decision-making and for all 

other purposes. For guidance on how to categorize devices, refer to the Instruction Manual. The 

number of devices loaned may exceed the number of loans reported in Section A since one loan 

may include more than one device. The total of i. must be greater than or equal to Section A line 

1 and ii must be greater than or equal to the sum of lines 2, 3 and 4 in Section A.

Type of AT Device Number of Devices

Decision-making All other Purposes Total 

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

i. Systemgeneratedii. Systemgeneratediii. System-generated
Device Loans

Page 22

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 Instruction Manual. 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.

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 borrowers who obtained device loans for the purpose of 

decision-making (the number reported in Section B i.). That data will be used to complete the 

table below. Refer to the Instruction Manual for guidance on how to categorize the primary 

purpose for which AT devices/services are needed. 

Response

Primary Purpose for Which AT is Needed Total

Education Employment Community Living

1. Decided that an AT 

device/service will meet 

needs (n,d)

2. Decided that an AT 

device/service will not 

meet needs (n,d)

3. Subtotal System-generated System-generated System-generated

4. Have not made a 

decision (d)

5. Subtotal System-generated System-generated System-generated

6. Nonrespondent 

(d, if > 35%)

7. Total System-generated System-generated System-generated Systemgenerated

8. Performance on this 

measure

System-generated System-generated System-generated

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

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

(System will generate an error message if total reported in column on far right does not equal total 

reported in Section B.i.) 

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 

(Narrative item) 

Impact area:  Education  Employment  Community Living 
Device Loans

Page 23

report data for this measure, statewide AT programs will collect follow-up information from 

borrowers to complete the table below. Refer to the Instruction Manual for guidance on how to 

categorize the primary purpose for which AT devices/services are needed. The number of 

borrowers reported must equal the total number reported in Section B ii. 

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 B ii.)

H. . Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the 

table below for all borrowers 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 24

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 to compare features to support decision making. 

Device demonstrations should not be confused with educational/training activities during 

which devices are demonstrated. Educational/training activities are instructional events designed 

to increase knowledge, skills, and competencies, generally for larger audiences or targeted

instruction for a small group focused on 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 individual, guided experience with the device(s) is provided to the 

participant decision-maker 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. A demonstration is characterized by 

its interactive nature whereby the participant can interact with an expert to increase their 

knowledge and understanding about the details and functions of a device; the participant drives 

the demonstration and has the ability to interact and have their individual questions about the 

device addressed. If the demonstration is conducted via the internet or distance learning 

mechanism it must be a real-time, interactive demonstration that provides one-on-one assistance 

to the participant. A web-based demonstration that is archived or is a static presentation without 

interaction is considered an awareness activity, not a demonstration. 

If a demonstration is to be conducted without the participant having direct (hands-on) access to 

the devices to be demonstrated, the interaction must be structured to ensure the device can be 

adequately explored to enable decision-making. For many types of AT devices, it will not be 

possible to provide adequate interaction in a demonstration without the device being in the hands 

of the participant. For example, a demonstration of a daily living aid like a “pill minder” might 

be done with the participant asking the demonstrator to fill, set and use the device while they 

watched on interactive video that might provide adequate information for decision-making. 
Device Demonstrations

Page 25

However, having a demonstrator “show” a Braille note taker to an individual with a vision 

disability via interactive video would not be adequate. 

Following a device demonstration, provision of information about a specific source where the 

customer may obtain additional information or services related to the devices demonstrated is 

reported as a referral. 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 referral service. 

Overview of Activities Performed

Did your approved State Plan for this reporting period include conduct device demonstrations? 

Check yes or leave unchecked. 

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 Instruction Manual. A device demonstration (counted as one) is defined as 

an occasion in which one or more devices within one AT category are demonstrated to an 

individual or small group one of whom 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 by the identified decision-maker 

participant. Most often the decision-maker is the individual with a disability who is exploring 

devices to meet their own needs. Other decision-makers include parents on behalf of their 

children and providers on behalf of agencies who are acquiring a device on behalf of a client. 

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
Device Demonstrations

Page 26

B. Types of Participants

In the table below, enter the number of individuals who participated in a device 

demonstration, by type. For guidance on how to categorize participants, refer to the Instruction

Manual. Report the type of individual who is making the decision for the demonstration (an 

individual with a disability on their behalf or other individual or behalf of an individual with a 

disability) separately from all other participants. The total number of decision-making 

participants (i. below) must equal the total number of demonstrations above in Section A since 

there is one decision-maker identified for each demonstration event who must provide the 

performance measure outcome. 

Type of Participant

DecisionmakerOther 

Participants

Total

Individuals with disabilities System-generated

Family members, guardians, authorized representatives System-generated

Representatives of Education System-generated

Representatives of Employment System-generated

Representatives of Health, allied health, rehabilitation System-generated

Representatives of Community Living System-generated

Representatives of Technology System-generated

Total i. Systemgenerated

SystemgeneratedSystem-generated

C. Number of Referrals

In this section, report the number of referrals made to each type of entity. Since participants in 

a demonstration may receive more than one referral, or may not be referred at all, the number of 

referrals may be greater or less than the number of participants and number of demonstrations. 

Do not include referrals to other components of your Statewide AT Program

Type of Entity Number of Referrals

Funding source (non-AT program)

Service provider

Vendor

Repair service

Others

D. Anecdote

Provide ONE anecdote about an individual who benefited from a device demonstration. For 

guidance on information to include in the anecdote, see Instruction Manual. If you have a picture 

to accompany the narrative, 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. 

(Narrative item) 

Impact area:  Education  Employment  Community Living 
Device Demonstrations

Page 27

E. Performance Measures

Device demonstrations are covered by the access performance measure. 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 Instruction Manual for guidance on how to 

categorize the primary purpose for which AT devices/services are needed. 

Response

Primary Purpose for Which AT is Needed

Education Employment

Community 

Living Total

1. Decided that an AT device/service 

will meet needs (n,d)

2. Decided that an AT device/service 

will not meet needs (n,d)

3. Subtotal System-generated System-generated System-generated

4. Have not made a decision (d)

5. Subtotal System-generated System-generated System-generated

6. Nonrespondent (d)

7. Total System-generated System-generated System-generated System-generated

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

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

Non-respondents are included in the denominator for calculation of performance. (System will generate 

an error message if total reported in column on far right does not equal total reported in Section A.)

F. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the 

table below for all customers served by device demonstration.

Customer Rating of Services Number of Customers Percent

Highly satisfied System-generated

Satisfied System-generated

Satisfied somewhat System-generated

Not satisfied System-generated

Nonrespondent System-generated

Total System-generated

Response rate System-generated

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

G. Notes

Describe any unique issues that may affect your data in this section (e.g., types of 

participants that may appear to be underrepresented because they receive demonstration services 

from another organization, types of devices/services that are not demonstrated because those 

demonstrations are available from another source, issues related to use of distance education 

mechanisms to deliver demonstrations, or issues related to dissatisfaction (e.g.; consumer may be 

dissatisfied because they assumed the AT Program could purchase the device for them).

(Narrative item)
Page 28

National Outcome Measures (ACL targets for national aggregate data)

Performance measure outcomes from each of the four state level activities are summed in the 

following tables for one overall acquisition and one overall access performance measure 

percentage. ACL began using this overall performance measure percentage for aggregate AT 

Program evaluation in FY18. The ACL National Target identified in each performance measure 

table is applied to summed national aggregate data for all 56 Section 4 grantees not to individual 

grantees as a met/not met criteria. It is provided in the acquisition and access performance 

measure tables below for informational purposes to be used at the discretion of the grantee. 

The consumer satisfaction rating and response rates from each of the four state level activities 

are also summed in the last table. ACL began using an overall consumer satisfaction and 

response rate for aggregate AT Program evaluation in FY18. The ACL National Targets 

identified in the consumer satisfaction rating and response rate table is applied to summed 

national aggregate data for all 56 Section 4 grantees not to individual grantees as a met/not met 

criteria. It is provided in the consumer satisfaction tables below for informational purposes to be 

used at the discretion of the grantee.

Overall Acquisition Performance Measure

The overall acquisition performance measure is the sum of State Financing, Reuse and Shortterm Device Loan (all purposes except decision-making) data and is used ONLY for national 

aggregate outcome purposes. This overall calculation includes only lines 1 and 2 in the 

numerator as it represents the percentage of recipients who were unable to afford or otherwise 

obtain the AT needed without the State AT Program. 

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 National Target 85%
Page 29

Overall Access Performance Measure

The overall access performance measure is the sum of Short-term Device Loan (decision-making 

purpose) 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 National Target 90%

Overall Satisfaction Rating 

The overall satisfaction rating is the sum of all four state level activities (State Financing, Reuse, 

Short-term Device Loan and Device Demonstration) satisfaction data. It represents the number 

of program beneficiaries who are highly satisfied or satisfied with state level activity services 

they received from the State AT Program. 

Customer Rating of Services Percent ACL National Target

Highly satisfied and satisfied System-generated 95%

Response rate System-generated 90%
Page 30

Educational /Training Activities

Outline

Overview of Activities Performed

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

B. Educational/Training topics

C. Description of educational/training activities

D. Notes

Section 4f requirements: Educational Activities/Training

1. “the number and general characteristics of individuals who participated in educational activities 

...(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 educational activities”

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

educational activities.”

Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that 

statewide AT programs provide educational activities 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 in 2004 provided a combined description of training and 

technical assistance. The 21st Century Assistive Technology Act, enacted 12/23/2022,

reauthorized the program and changed the term “training” to “educational activities.” In general, 

education provides theoretical knowledge while training provides practical skills and the APR 

has historically defined training as inclusive of both. Following is guidance on what activities to 

report in this section and how to distinguish educational/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 educational/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 an educational/training event or 

a technical assistance initiative.

Educational/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, inperson, or via telecommunications or other distance education mechanisms. In general, 

participants in educational/training activities can be individually identified and could complete 

an evaluation of the educational/training event. Examples of educational/training activities 

include classes, workshops, and presentations that have a goal of increasing skills, knowledge, 

and competency, as opposed to something intended only to increase general awareness of AT.

Distinguishing Educational/Training Activities from Public Awareness Activities

Educational/training activities have more depth and breadth than public awareness activities 

and are focused on skill building and competency development. If the purpose of an 
Page 31

educational/training session is to create awareness, the session should be classified as a public 

awareness activity. In general, participants in educational/training events can be individually 

identified, while in awareness activities, it may not be possible to identify each participant 

individually. 

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 Educational/Training Activities from Technical Assistance

Educational/Training activities are 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 

typically involves multiple contacts and interactions over an extended period of time. 

In some cases, educational/training activities may be a component of technical assistance. 

Educational/training activities provided as part of technical assistance can be reported here, but 

only if the educational/training activity was supplemented by other technical assistance activities. 

If an educational/training activity was the only technical assistance service provided, it can be 

reported as either educational/training or technical assistance, but not both. 

Overview of Activities Performed 

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

A. Educational/Training Participants: Number and Types of Participants; Geographical 

Distribution 

1. Enter the number of educational/training participants by type. The participant may selfdetermine the appropriate descriptor for themselves or such information may be derived 

from other educational/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 educational/training events, 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. 
Page 32

Participants for whom you cannot determine a county are counted in “Unknown.” For 

additional guidance on the RUCC, refer to the Instruction Manual. 

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

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

Educational/Training Topics

Enter the number of participants by the primary content of the educational/training event

organized into the following 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 and Communication Technology (ICT) Accessibility including web access, 

software accessibility, procurement of accessible ICT, and similar. For participants in 

this topic, you will need to collect a performance measure, see below.) 

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 Educational/Training Activities

Number of 

Educational/Training 

Participants

1. AT Products/Services

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

Focused on funding sources and related laws, policies, and procedures 

required to implement and deliver access to AT devices/services and related.

3 Combination of 1 and 2 above

AT Products/Services and AT Funding/ Policy/Practice

4.Information and Communication Technology (ICT) Accessibility

Focused on accessible information and communication technology (ICT) 

including web access, software accessibility, procurement of accessible ICT

A performance measure

must be collected for these 

participants

5. Transition 

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 Educational/Training Participants must equal the Total in A(1) and 

A(2).
Page 33

B. Description of Educational/Training Activities

1. Briefly describe one innovative or high-impact educational/training activity conducted 

during this reporting period. Note who conducted the event (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 event. In another sentence, 

summarize the positive result or intended impact of the event. Do not include overall 

descriptions of conferences held, unless the conference had a unique purpose/outcome. 

2. Briefly describe an educational/training activity related to transition conducted during 

this reporting period. Note who conducted the event (e.g. expertise of staff) and 

characteristics of the audience (including number that attended). In one sentence, 

describe the topic, content, and/or approach of the event. In another sentence, summarize 

the positive result or intended impact of the event. Do not include overall conference 

descriptions absent a unique purpose/outcome. This section must be completed unless 

you report transition technical assistance activities. If this section is completed, an 

associated number of participants must be reported in Section B Row 5.

3. Briefly describe an educational/ training activity related to Information and 

Communication Technology (ICT) accessibility conducted during this reporting period. 

Note who conducted the event (e.g., expertise of staff) and characteristics of the 

audience (including number that attended). In one sentence, describe the topic, content, 

and/or approach of the event. In another sentence, summarize the positive result or 

intended impact of the event. This section must be completed if you have attendees 

reported in the ICT accessibility topic area in Section B Row 4. 

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

Outcome/result from ICT Accessibility Education/Training Received Number

ICT accessibility procurement or development policies, procedures, or practices 

will be improved or better implemented to ensure accessibility. (n,d)

Education/Training or technical assistance activities will be developed or

implemented to ensure accessibility of ICT. (n,d)

No known outcome at this time. (d) 

Non-respondent (d) 

TOTAL (must equal number reported in Section B.3) System-generated

Performance Measure Percentage System-generated

E. Notes

Describe any unique issues that may affect the data in this section, (e.g. why particular 

topics or audiences were emphasized or were not included during this reporting period). 

(Narrative item)

Narrative item- Each narrative is limited to 3000 characters.

Narrative item- Each narrative is limited to 3000 characters.

Narrative item- Each narrative is limited to 3000 characters.
Page 34

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 educational/training activities 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 21st Century Assistive Technology Act provides a combined description of 

educational/training and technical assistance activities. Additional descriptions of technical 

assistance are provided below, along with guidance for distinguishing technical assistance from 

public awareness and educational/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 educational/training are reported in that section. 

Reminder- each Statewide AT Program must report on at least one transition activity related to 

school transition (e.g., secondary school to post-school) AND one transition activity related to 

community living (e.g. maintaining or transitioning to community living). The activity reported 

may be either an educational/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 35

Distinguishing Technical Assistance from Educational/Training Activities

Educational/Training activities are 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, educational/training activities may be a component of technical assistance. 

Educational/Training events provided as part of technical assistance can be reported in the 

training section, but only if the educational/training activity was supplemented by other technical 

assistance activities. If an educational/training activity was the only technical assistance service 

provided, it can be reported as either educational/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 TA activity must be described in Section B and a transition TA activity must 

be reported unless a transition educational/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 
Page 36

the topic, content, and/or approach of the technical assistance; and (2) summarize the 

positive result or impact of the technical assistance.

Narrative item- Each narrative is limited to 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 educational/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 37

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 Educational/Training Activities 

The intended outcome of an activity should determine whether it is reported under public 

awareness or educational/training activities. Include presentations made for the purpose of 

general awareness under public awareness. Do not include sessions with the intended outcome of 

participants applying new knowledge or skills in addressing AT device/service issues (which 

should be reported under educational/training activities). 

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. Educational/training 

sessions with the intended outcome of participants applying new knowledge or skills in

addressing AT device/service issues should be reported as an educational/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 38

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. Also, please identify any partnerships that were used 

to support the awareness activity (e.g. partnering with AAAs to disseminate information to 

older adults, with CILs to disseminate information to individuals with disabilities, with 

professional associations (OT/PT/SLP), etc.) 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 39

In addition to reporting the quantities of individuals you provided information and assistance to, 

it is also helpful to know how these individuals learned about the state AT program.

Understanding how people are learning about the state AT program enables programs to enhance 

and refine public awareness and outreach activities. Please provide a narrative description that

reflects a qualitative assessment of outreach and education and the types of referrals that 

increased referrals to the state AT program as a result of that effort. The description should 

include: 

• Unique strategies and/or partnerships used in the outreach strategy that were particularly 

helpful in increasing referrals

• Information about the referral source types that were increased as a result of the outreach 

activity (e.g., increased referrals from agencies such as Area Agencies on Aging (AAA),

Centers for Independent Living (CIL), etc. and/or from other types of service providers,

such as health care practitioners, educators, rehabilitation counselors, etc.) Numeric data 

is helpful but not mandatory in describing the increased referral results. 

It is also helpful to have information about the types of referral sources that are referring people 

to the AT program for Information and Assistance. The information reported will be valuable in 

understanding the types of referral sources and identifying opportunities to build and/or 

strengthen partnerships to expand awareness of state AT programs and serve those with 

disabilities across all geographies in a state. In the box below please provide a narrative 

description of the types of entities/practitioners that refer people to the AT program. It is helpful 

to include estimates on the percentage of the total referrals coming from each referral source in 

the narrative and the geographical reach of these referral sources. For example, we work with all 

30 libraries across the state resulting in statewide coverage and regularly receive referrals from

all of them. Approximately 25% of our total referrals for information and assistance come from 

libraries.

C. Notes: Describe any issues with your data in this section. 

(Narrative item)

(Narrative item)
Page 40

Coordination/Collaboration and State Improvement Outcomes

Outline

Overview of Activities Performed

A. Coordination/Collaboration Partnership Initiatives

B. State improvement outcome

Section 4(e)(4)(B) requirements: “(B) FEDERAL PARTNER COLLABORATION.—In order to 

coordinate efforts regarding the availability of funding to access and acquire assistive technology 

through device demonstration, loan, reuse, and State financing activities, a State receiving a grant 

under this section shall ensure that the lead agency or implementing entity is conducting outreach to 

and, as appropriate, collaborating with, other State agencies that receive Federal funding for assistive 

technology, including— (i) the State educational agency receiving assistance under the Individuals with 

Disabilities Education Act (20 U.S.C. 1400 et seq.); ii) the State vocational rehabilitation agency 

receiving assistance under title I of the Rehabilitation Act of 1973 (29 U.S.C. 720 et seq.); (iii) the 

agency responsible for administering the State Medicaid program under title XIX of the Social Security 

Act (42 U.S.C. 1396 et seq.) (iv) the State agency receiving assistance under the Older Americans Act 

of 1965 (42 U.S.C. 3001 et seq.); and (v) any other agency in a State that funds assistive technology.”

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 

Coordination/Collaboration is a required state leadership activity (Section 4(e)((3)(C) for all 

grantees. The AT Act also requires goals in a variety of areas and the recent reauthorization 

added the area of “access to tele assistive technology to aid in the access of health care services, 

including mental health and substance use disorder services.” A partnership in that area could be 

reported in this section using the focus area of Information and Communication Technology / 

Remote Connectivity. The recent reauthorization also requires outreach to agencies that receive 

federal funding for AT and collaboration as appropriate to increase the funding for device 

demonstration, loan, reuse and state financing activities.

Please report on outreach efforts and collaboration as appropriate with these identified agencies. 

You may also report additional partnerships that increase access to and acquisition of AT for this 

reporting period. Examples of partnership initiatives include collaborating with the aging 

network to provide AT demonstration toolkits for each Area Agency on Aging or teaming up 

with the state education agency to distribute AT needed for remote learning or partnering with 

Centers for Independent Living to increase access to reused AT.

State improvement outcome reporting is optional, but ACL strongly emphasizes the importance 

of partnerships to expand the AT programs’ reach to unserved target populations and reporting 

this information will improve the ability to replicate successful partnerships in other states and 

improve overall program outcomes. You may report up to two MAJOR state improvement 

outcomes for this reporting period. (For example, you may have worked with your state 

Information Technology Office to implement an Executive Order related to web accessibility or 
Survey Instrument Access Performance Measure

Page 41

may have worked with your Medicaid office to streamline procedures for obtaining wheeled 

mobility devices.) 

A. Coordination/Collaboration Partnership Initiatives

Did you conduct outreach to the State Education Agency, State Vocational Rehabilitation 

Agency, State Medicaid Agency, State Unit on Aging and what was the result? (For each agency 

indicate Yes/No, if no outreach explain why not – narrative field. Drop-down result: No 

collaboration implemented (explain why not) or collaboration implemented complete Questions

1-4 for each agency.)

Complete this section for each coordination/collaboration partnership initiative reported.

1. As concisely as possible, describe the partnership initiative. What activities/services 

were provided? Who are the major collaborating organizations and what is their role? 

Who is served/benefited? What funding was used to implement the initiative? (Text) 

2. As concisely as possible, describe the measurable results of the initiative and any lessons 

learned. How did access to AT change because of the coordination / collaboration /

partnership? How did awareness of AT change as a result of the partnership? How did 

the reach of the state AT program change as a result of the partnership? What made the 

partnership successful? What would you change or wish you had done differently? 

Provided funding/resources are available, will the initiative continue or is this a one-time 

event? What advice would you give for replication of the initiative? Please include 

URL for initiative if available. (Narrative field)

3. What focus areas(s) were addressed by the initiative? Drop-down list: Education, 

Employment, Housing/Home Automation, Transportation, Community Participation and 

Integration, Recreation/Leisure, Health, Aging, Transition (school to work or 

congregate care to community), Aging and Disability Network/No Wrong Door, 

Veterans, Information and Communication Technology/Remote Connectivity, Other.

4. What AT Act authorized activity(s) were addressed? Drop-down list: SFA, Reuse, 

Device Loan, Demo, Educational/Training Activities, TA, I&A, PA.

B. State Improvement Outcomes

Complete this section for each 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 AT). 

If you have a second MAJOR outcome to report, complete items 1 through 3 above again. 
Survey Instrument Access Performance Measure

Page 42

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 as included in your State Plan for AT. Report only actual dollars leveraged. 

Do NOT report in-kind contributions. Do NOT report ongoing AFP endowments or matching 

funds. Additional and leveraged funding reported in this section is NOT necessarily considered 

program income under federal guidelines.

A. Leveraged Funding for State Plan Activities 

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. The definitions of each 

category are as follows: 

Federal – Grants that are received directly by the State AT Program from federal agencies, 

e.g. HHS/ACL, ED/OSEP, etc.

Public/State Agency – Grants, contracts, memorandum of understanding and similar 

agreements between the State AT Program and state or other public agencies with 

associated dollars, e.g. federal flow through, dedicated state funds, etc.

State Appropriations – State dollars/general state funds directly appropriated for use by the 

State AT Program;

Private – Grants, contracts, memorandum of understanding and similar agreements with 

private agencies funded with dollars that can be of any type. 

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.

Identify if data associated with this leveraged funding has been reported or not. For most 

leveraged funding entries, the number of individuals served or other outcome data should have 

already been reported in the appropriate previous sections of this Annual Performance Report. 
Survey Instrument Access Performance Measure

Page 43

However, there may be rare extenuating circumstances in which a program reports leveraged 

funding in this section but is unable to report data in the associated section of the APR, e.g. a AT 

educational/training event funded by an external source did not allow for information to be 

collected in a way that could be reported in the educational/training activities section of the APR. 

In that case, you should indicate that data was not reported and provide a narrative explanation. 

Fund Source (select one) Amount Use of Funds (select one) Data Reported (select one)

▪ Federal 

▪ Public/State Agency

▪ State Appropriations

▪ Private

▪ State Financing

▪ Educational/Training

▪ Reuse

▪ Technical Assistance

▪ Demonstration

▪ Public Awareness/I&A

▪ Device Loan

▪ Yes, data was reported in 

previous section of APR

▪ No, data was not reported 

in previous section of 

APR and an explanation 

is provided

option to repeat row data 

For any leveraged funding reported above for which data could not be reported, please describe the 

extenuating circumstances that precluded data from being reported and efforts to remediate the 

situation in future reporting periods. 

(Narrative item)

B. Notes

 Describe any unique issues with your data in this section including any leveraged funding your 

program received that was used to support activities authorized by the AT Act but those 

activities were not included in your State Plan for AT with an explanation of why such activities 

were not part of the State Plan. 

(Narrative item)
Survey Instrument Access Performance Measure

Page 44

Data Collection Instrument

Access Performance Measure 

TO BE COMPLETED BY PROGRAM STAFF ID (optional) ____________

Services provided:

 Device demonstration

 OR

 Device loan (decision-making purpose)

Date service delivery was completed: __________

Date this form was received: ____________________

Please answer the following questions about the services you received from the (insert name of 

statewide AT program or its subcontractor). We need this information to provide high quality 

services and to meet the requirements for receiving federal funding. 

1. The primary purpose for which I need (or the person I represent needs) an AT device or 

service is related to:

(Please mark only one answer.)

 Education—participating in any type of educational program

 Community living—carrying out daily activities, participating in community activities, 

using community services, or living independently

 Employment—finding or keeping a job; getting a better job; or participating in an 

employment training program, vocational rehabilitation program, or other program 

related to employment

2. What kind of decision about AT devices or services were you (or someone you represent) 

able to make after your device demonstration or device loan?

(Please mark only one answer.)

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

represent).

_____ Decided that AT device(s) or service(s) 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 45

Data Collection Instrument

Acquisition Performance Measure (SFA and Reuse)

TO BE COMPLETED BY PROGRAM STAFF ID (optional) ____________

Services provided:

 “State financing” services—including financial loan, assistance in accessing funds for AT 

devices/services, assistance in obtaining AT devices and services at reduced cost or 

free, or other related services

 Device reuse— received an AT device through a device exchange, reassignment/refurbish 

or repair or open-ended loan program

Date service delivery was completed: __________

Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of 

statewide AT program or its subcontractor). We need this information to provide high-quality 

services and to meet the requirements for receiving federal funding. 

1. The primary purpose for which I need (or the person I represent needs) an AT device or 

service is related to:

(Please mark only one answer.)

 Education—participating in any type of educational program

 Community living—carrying out daily activities, participating in community activities, 

using community services, or living independently

 Employment—finding or keeping a job; getting a better job; participating in an 

employment training program, vocational rehabilitation program, or other program 

related to employment

2. Why did you choose to obtain AT devices/services from our program?

(Please mark only one answer.)

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

programs.)

 _____ The AT was only available to me through this program. (I am not eligible or don't 

qualify for other programs, the AT is not covered by other funding sources or the 

specific device I needed is not provided by other programs.)

_____ The AT was available to me through other programs, but the system was too 

complex or the wait time was too long.

_____ None of the above

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. The valid OMB control number for this 

information is 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 46

Data Collection Instrument

Acquisition Performance Measure (Device Loan)

TO BE COMPLETED BY PROGRAM STAFF ID (optional) ____________

Short-term device loan purposes:

 Providing loaner equipment during device repair or while waiting for funding

 Providing an accommodation for a time-limited event 

 Conducting educational/training or other professional development activity

Date service delivery was completed: __________

Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of 

statewide AT program or its subcontractor). We need this information to provide high-quality 

services and to meet the requirements for receiving federal funding. 

1. The primary purpose for which I need (or the person I represent needs) an AT device or 

service is related to:

(Please mark only one answer.)

 Education—participating in any type of educational program

 Community living—carrying out daily activities, participating in community activities, 

using community services, or living independently

 Employment—finding or keeping a job; getting a better job; participating in an 

employment training program, vocational rehabilitation program, or other program 

related to employment

2. Why did you choose to borrow AT devices/services 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(s) I 

needed are 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 device(s) 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 47

Data Collection Instrument

Information and Communication Technology Accessibility

Performance Measure

TO BE COMPLETED BY PROGRAM STAFF ID (optional) ____________

IT/Telecom Educational/Training Session 

Date session 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 

educational/training event on Information and Communication Technology (ICT) accessibility?

(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

 _____ Educational/Training activities will be developed/implemented to ensure 

accessibility of websites, software or other ICT (web, software, etc.) 

_____ Outcome is unknown at this time. 

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. The valid OMB control number for this 

information is 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.
Survey Instrument Consumer Satisfaction

Page 48

Survey Instrument

Customer Satisfaction

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

Services provided:

 Device demonstration

 Device short-term loan

 State financing programs —including financial loan, direct provisions of AT or acquisition 

of AT for a reduced cost. 

 Device reuse programs —including device exchange, or refurbish/repair with 

reassignment or open-ended loan 

Date service delivery was completed: __________

Date this form was received: ____________________

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

received? 

(Check one.)

_____ Highly satisfied

_____ Satisfied

_____ Satisfied somewhat

_____ Not at all satisfied

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. The valid OMB control number for this 

information is 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.