Survey Instrument Consumer Satisfaction

**Administration for Community Living**

**State Grants for Assistive Technology Program**

**Annual Progress Report (AT APR)**

**Data Collection Instrument**

OMB # 0985-0042

Expires: 11/30/2020

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 404 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required under the Assistive Technology Act of 1998, as amended, applicable to Section 4 formula funded grantees for the State Grant for Assistive Technology Program. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Robert Groenendaal, Administration for Community Living, 330 C Street, SW, Washington, DC  20201.   

**This document was prepared by the Center for Assistive Technology Act Data Assistance under Grant No. 90ATTA0002-01-00 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 AT Act of 1998, as amended (P.L. 108-364) (AT Act of 2004).  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 Information3

State Financing4

Reuse14

Device Loans19

Device Demonstrations24

National Outcome Measures28

Training30

Technical Assistance34

Public Awareness and Information and Assistance37

State Improvement Outcomes39

Additional and Leveraged Funds40

Data Collection Instrument Access Performance Measure42

Data Collection Instrument Acquisition Performance Measure43

Data Collection Instrument ICTAccessibility Training Performance Measure45

Survey Instrument Customer Satisfaction46

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Page 43 

Page 1

# General Information

# 

# State Financing

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 State-financed or privately financed alternative financing systems of subsidies.  Examples of state financing activities include, but are not limited to administering financial loan programs, administering “last resort” activities funded with non-AT Act dollars, administering cooperative buying programs, administering telecommunications distribution programs, and other activities 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.*

## 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*.*  Do not report loans in which the financial loan program had no explicit financial or administrative investment and no subsidy was provided, such as loans for which you provide information and assistance type services and refer to a lending source who makes the loan. 

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.  

#### 2. Income of Applicants to Whom Loans Were Made

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

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

Lowest:	$______________

Highest:	$______________

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

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.  

*(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.

*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.  

*(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.  

#### 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. 

**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.

*(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.)  

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

## *6.  Defaults*

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

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

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

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

#### 1. Overview of Activities Performed  

How many other state financing activities that provide consumers with access to funds for the purchase of AT devices and services were included in your approved State Plan?  – *enter number*.  *Which of the following best describes this state financing activity? Drop-down box: (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.  

(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).  

## 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 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. 

*(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).  

## 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.   

****
*(Narrative item #1)*

Impact area:       Education       Employment       Community Living 

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

****
*(Narrative item #2)*

Impact area:       Education       Employment       Community Living 

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 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).  

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.

*(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).  

*State Financing*

## 

Page 3 

# Reuse

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 have some intermediary role in making the exchange as there is no longer an automatic opt-out available for device exchange performance measure data. If the device buyer and seller make the exchange transaction without any intermediary involvement of the Statewide AT Program it will not be possible 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.

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. 

(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:  _________________________________________

**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.  

## 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. 

## 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.   

****
*(Narrative item)*

Impact area:       Education       Employment       Community Living 

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. 

*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.  

*(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.  

Reuse

Page 14 

# Device Loans

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

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

## Overview of Activities Performed

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

## A. Short-Term Device Loans by Type of Purpose

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

1) To make a decision (one decision 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.

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

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

## 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 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. 

## 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. 

## 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.   

****
*(Narrative item)*

Impact area:       Education       Employment       Community Living 

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.  

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 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.    

*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.)

## 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.)   

Device Loans

Page 19 

# Device Demonstrations

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 training activities during which devices are demonstrated.  Training activities are instructional events designed to increase knowledge, skills, and competencies, generally for larger audiences.  Training can also be targeted/focused instruction for an individual or small group (such as in-depth training for an individual consumer on a specific AT device).  This targeted training is for skill development whereas device demonstrations are for decision-making purposes.  Device demonstrations also should not be confused with public awareness activities at which devices are demonstrated.  The key difference is that device demonstrations are intended to enable an individual to make an informed choice rather than merely making him or her aware of a variety of AT.  

In a device demonstration 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. 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. 

## 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.  

## 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

## 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.   

****
*(Narrative item)*

Impact area:       Education       Employment       Community Living 

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

## 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. 

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.

*(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). 

Device Demonstrations

Page 24 

# National Outcome Measures (not included in individual APR)

## Overall Acquisition Performance Measure (national aggregate data only)

The overall acquisition performance measure is the sum of State Financing, Reuse and Short-term 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. 

## Overall Access Performance Measure (national aggregate data only) 

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

## Overall Satisfaction Rating (national aggregate data only)

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.  

# Training

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

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

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

#### Distinguishing Training Activities from Public Awareness Activities

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

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

#### Distinguishing Training from Technical Assistance

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

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

## Overview of Activities Performed 

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

## A. Training Participants: Number and Types of Participants; Geographical Distribution 

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

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

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

## B. Training Topics

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

Training topics are organized into categories: 

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

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

3. Information and Communication Technology (ICT) Accessibility Training including web access, software accessibility, procurement of accessible ICT, and similar.  **For participants in this training topic, you will need to collect a performance measure, see Data Collection Instrument ICT Accessibility Training Performance Measure.**

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

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

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

## C. Description of Training Activities

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

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

2. Briefly describe a training activity related to transition conducted during this reporting period.  Note who conducted the training (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 training. In another sentence, summarize the positive result or intended impact of the training.  Do not include overall conference descriptions absent a unique purpose/outcome.  **This section must be completed unless you are reporting transition technical assistance activities**.  **If this section is completed, an associated number of training participants must be reported in Section B Row 5**.  

3. Briefly describe a training activity related to Information and Communication Technology (ICT) accessibility conducted during this reporting period.  Note who conducted the training (e.g., type of expertise of staff) and characteristics of the audience (including number that attended).  In one sentence, describe the topic, content, and/or approach of the training.  In one sentence, summarize the positive result or intended impact of the training.  **This section must be completed if you have attendees reported in the ICT accessibility topic area in Section B Row 4**.  

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

## 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).  

Page 28

# Technical Assistance

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

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

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

#### Distinguishing Technical Assistance from Information & Assistance 

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

#### Distinguishing Technical Assistance from Training

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

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

## Overview of Activities Performed

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

## A.	Frequency and Nature of Technical Assistance 

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

## B.  Description of Technical Assistance Activities

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

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

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

## 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).

Technical Assistance

Page 34

# Public Awareness and Information and Assistance

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

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

***Distinguishing Information and Assistance from Device Demonstration Referral***

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

***Distinguishing Public Awareness from Training***

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

## Overview of Activities Performed

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

## A. Public Awareness Activities

In this section report on one or two high impact public awareness activities.  This can include newsletters (paper or digital), listservs, blogs, social media, web based information, public service announcement via television, radio, online broadcasts, podcasts, internet streamed or live presentations, or many other mechanisms designed to disseminate awareness level information to a wide audience. Please remember that presentations reported in this section are for the purpose of general awareness.  Training sessions with the intended outcome of participants applying new knowledge or skills in addressing AT device/service issues should be reported as a training activity.  (NOTE:  Purchasing promotional items is not allowable under OMB Circular direction and as such should not be reported in this section as a public awareness activity.) 

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.  

## 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.  

## In addition to learning the quantities of individuals you provided information and assistance to, it is also helpful to ask these individuals how they learned about the state AT program.  Understanding how people are learning about the state AT program enables us to enhance and refine our public awareness and outreach activities.  Using your state’s outreach strategies, please complete the table below based on responses from those served.

## C. Notes

**Describe any unique strategies and partnerships you’ve developed that contributed to increased referrals to state AT programs compared to the previous year also include any issues with your data in this section.**

Public Awareness and Information and Assistance

Page 37

# Coordination/Collaboration and State Improvement Outcomes

## Overview of Activities Performed 

Coordination/Collaboration and Partnerships are essential in responding to the increased demand for technology training, demonstrations, and short term loans. Reporting partnership activities enables other programs to identify partnership activities that can be replicated to increase access to assistive technology.  Partnerships can help reach a broader universe of people with disabilities across all geographies and points of access in a state. This is particularly important in larger states and states with rural geographies where people with disabilities are not likely to have easy access to the physical location of an AT program. 

Coordination/Collaboration partnership initiative reporting is optional. State AT programs may have a multitude of partnerships. Please report up to two partnerships that increase access to assistive technology for this reporting period.  Examples of partnership initiatives include collaborating with the state aging network to provide Assistive Technology 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 awareness and access to assistive technology for people with disabilities. Partnerships with AT programs have been encouraged and incorporated into ACL funding of State Health Insurance Assistance Programs and Aging and Disability Resource Centers in every state in 2020. 

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 may have worked with your Medicaid office to streamline procedures for obtaining wheeled mobility devices.) 

## A. Coordination/Collaboration *Partnership* Initiatives

Complete this section for each coordination/collaboration partnership initiative to be 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? (*Narrative field)*

2. As concisely as possible, describe the measurable results of the initiative and any lessons learned.  How did access to AT change as a result 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 box: List TBD*

4. What AT Act authorized activity(s) were addressed? *Drop-down box:  SFA, Reuse, Device Loan, Demo, Training, 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).*

## B 	State Improvement Outcome

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

# Additional and Leveraged Funds

## 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.  However, there may be 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 training funded by an external source did not allow for information to be collected in a way that could be reported in the previous training section.  In that case, you should indicate that data was not reported and provide a narrative explanation. 

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.  

## 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. 

Data Collection Instrument

**Additional and Leveraged Funds**

Page 40

# Data Collection InstrumentAccess Performance Measure 

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. 

***Survey Instrument Access Performance Measure***

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# Data Collection InstrumentAcquisition Performance Measure (SFA and Reuse)

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.

*Survey Instrument Acquisition Performance Measure*

Page 45

# Data Collection InstrumentAcquisition Performance Measure (Device Loan)

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. 

*Survey Instrument Acquisition Performance Measure*

Page 46

# 

# Data Collection InstrumentInformation and Communication Technology Accessibility Training Performance Measure 

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

What do you anticipate will be the primary outcome of your participation in this training on Information 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

      _____	Training 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 Acquisition Performance Measure*

# Survey InstrumentCustomer Satisfaction

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

***(Check one.)***

_____ Highly satisfied

_____ Satisfied

_____ Satisfied somewhat

_____ Not at all satisfied

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.