Rehabilitation Services Administration

Annual Progress Report for

State Grants for Assistive Technology 

Public Reporting Burden

OMB # 1820-0572

Expires:

Paperwork Burden Statement

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

to a collection of information unless such collection displays a valid OMB control 

number. Public reporting burden for this collection of information is estimated to average 

402 hours per response, including time for reviewing instructions, searching existing 

data sources, gathering and maintaining the data needed, and completing and 

reviewing the collection of information. The obligation to respond to this collection is 

required under the Assistive Technology Act of 1998, as amended to retain benefit of 

the State Grant for Assistive Technology Program. Send comments regarding the 

burden estimate or any other aspect of this collection of information, including 

suggestions for reducing this burden, to the U.S. Department of Education, 400 

Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and 

reference the OMB Control Number 1820-0572.

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

Assistance under Grant No. H224B110002 from the U.S. Department of Education

Table of Contents

General Information......................................................................................................... 1

State Financing ............................................................................................................... 2

Reuse............................................................................................................................ 18

Device Loans ................................................................................................................ 21

Device Demonstrations ................................................................................................. 26

Overall Performance Measures..................................................................................... 30

Training ......................................................................................................................... 31

Technical Assistance..................................................................................................... 35

Public Awareness and Information and Assistance....................................................... 38

State Improvement Outcomes....................................................................................... 40

Additional and Leveraged Funds................................................................................... 41

Data Collection Instrument Access Performance Measure ........................................... 43

Data Collection Instrument Acquisition Performance Measure ..................................... 44

Data Collection Instrument IT/Telecommunications Training Performance Measure.... 46

Survey Instrument Customer Satisfaction ..................................................................... 47

Instructions for completion of this form and relevant definitions are contained

in a separate document, “Instruction Manual and Definitions for the Annual 

Progress Report for State Grants for Assistive Technology.”
Page 1

General Information

1. General Information

Statewide AT Program 

1. State and Program Title

Lead Agency

2. Agency name

3. Mailing address 8. Fax

4. City 9. Program URL

5. State 10. Program E-mail

6. Zip code 11. Program toll-free number  Check if in 

state only

7. Phone 12. Program TTY number

Implementing Entity

13. Check here if not applicable. If applicable, complete Items 14–24. 

14. Name of implementing entity

15. Mailing address 20. Fax

16. City 21. Program URL

17. State 22. Program E-mail

18. Zip code 23. Program toll-free number  Check if in 

state only

19. Phone 24. Program TTY number

Program director and other contacts

25. Program Director at Lead Agency (last, first)

26. Title

27. Phone

28. E-mail

29. Name of Program Director at Implementing Entity (last, first) – If applicable

30. Title

31. Phone

32. E-mail

Person Responsible for completing this form is other than Program Director 

33. Name (last, first)

34. Title

35. Phone

36. E-mail

Certifying Representative

38. Name (last, first)

39. Title

40. Phone

41. E-mail
State Financing

Page 2

State Financing

Outline 

Overview of Activities Performed

A. Financial loan programs

1. Loan applications

2. Income of applicants to whom loans were made

3. Loan type 

4. Interest rates

5. Types and dollar amounts of AT financed

6. Defaults

7. Additional Data for Title III Funded AFP

B. State financing activities that provide consumers with resources and services that 

result in the acquisition of AT devices and services

1. Overview of Activities Performed

2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and 

Services and Number for whom Performance Measure Data are Collected

3. Types and dollar amounts of AT funded

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

1. Overview of Activities Performed

2. Geographic Distribution and Number of Individuals Served

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

D. Anecdote

E. Performance measures

F. Customer Satisfaction

G. Notes

Section 4f requirements: (1) the type of State financing activities...used by the State; (2) 

the amount and type of assistance, including the number of applications for assistance 

received, the number of applications approved and rejected, the default rate for the 

financing activities, range and average interest rate for the financing activities, range 

and average income of approved applicants for the financing activities, and the types 

and dollar amounts of AT financed; (3) consumers of the State financing activities, who 

shall be classified by type of AT device or service and geographical distribution

A state financing activity is an activity approved as part of your State Plan for AT, such 

as the development of systems: to provide and pay for AT, for the purchase, lease, or 

other acquisition of, or payment for AT; or of State-financed or privately financed 

alternative financing systems of subsidies.

Examples of state financing activities include, but are not limited to administering 

financial loan programs, administering “last resort” activities funded with non-AT Act 
State Financing

Page 3

dollars, administering cooperative buying programs, administering telecommunications 

distribution programs, and other activities designed to provide consumers with 

resources and services that result in the acquisition of AT devices and services.

Overview of Activities Performed 

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

Financing activities? – check yes or leave unchecked. If yes complete one or more of 

sections A, B, or C.

A. Financial Loan Programs

Did your approved State Plan include conducting a financial loan program? (Do not 

include Access to Telework in this report.) – check yes or leave unchecked.

If yes -- is this financial loan program a Title II Alternative Financing Program? – check 

yes or leave unchecked. If only the first question is checked yes, Items 1-6 of Section A 

will be completed. If both questions are answered yes, Item 7 of Section A will also be 

completed.

1. Loan Applications

In this section, report on: (1) revolving loans that are made directly by the Statewide AT 

Program; and (2) partnership loans that use dollars from another source, usually a 

financial institution, in which the statewide AT program has an investment through loan 

guarantee, agreement with a financial institution based on an investment deposit, 

interest or principal buy-down, or other financial or administrative role. Do not include 

loans in which the statewide AT program had no financial or administrative role, such as 

loans for which you simply made a referral to a lending source.

In the table below, report information on loan applications made by Rural Urban 

Continuum Code (RUCC) of the applicant’s county of residence and the decisions made 

about those applications. Include all applications that were processed to one of the 

three decisions shown in the table below (i.e., approved—loan not made, approved—

loan made, or rejected) during this reporting period, even if the application was received 

prior to the start of the reporting period. Do not include applications that were not 

reviewed because they were not complete, were withdrawn before a final decision was 

made, or were still pending at the end of the reporting period. For guidance on how to 

classify the applicant’s area of residence as metro or non-metro, please see the 

“General Instructions.”
State Financing

Page 4

Number of Applications

Area of Residence Total

Metro

RUCC 1-3

Non-Metro

RUCC 4-9

A.Approved—loan made Systemgenerated

B.Approved—loan not made (i.e., the 

application was withdrawn after the loan 

was approved, or the loan was approved but 

not accepted by the consumer)

Systemgenerated

C.Rejected Systemgenerated

D.Total Systemgenerated

SystemgeneratedSystemgenerated

Income of Applicants to Whom Loans Were Made

This section collects data about the income of applicants to whom loans were made 

(i.e., those who were counted in row A of the table in Section B, Item 1above). For 

purposes of this section, the income of these applicants is the gross annual income that 

the applicants reported on the loan applications (i.e., the amount upon which the 

decision about the loan was based). This may be the income of the individual, the 

family, and/or one or more co-borrowers.

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 in Section B, Item 1 above to calculate the 

average income.

A B C

Sum of 

Incomes

Number of Applicants to Whom 

Loans Were Made

Average Gross

Annual Income

$ System-generated System-generated

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 table in Section B, Item 1
State Financing

Page 5

above. The system will calculate the percentage of loans made to individuals 

in each income category.

Number and Percentage of Loans 

Made to Applicants with Incomes of

Total

$15,000

or Less

$15,001 

to 

$30,000

$30,001 

to 

$45,000

$45,001 

to 

$60,000

$60,001 

to 

$75,000

$75,001 

or More

Number of 

loans

System

-

genera

ted

Percentage 

of loans

SystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystem

-

genera

ted

(System will generate an error message if total number of loans does not match number 

reported in row A of the table in Section A.1.)

2. Loan Type

a) Enter the number of partnership loans by loan type. Any row left blank will 

automatically count the number of loans as zero. The system will calculate the 

percentage of loans that fall into each category. For guidance on how to categorize 

partnership loans, refer to the instructions. Report each loan in only one category.

Type of Loan Number 

of Loans

Percentage 

of Loans

Revolving Loan - Low Interest (prime or less) Systemgenerated

Revolving Loan – Preferred Interest (greater 

than prime)

Systemgenerated

Low interest (prime or less)

 Without interest buy-down or loan guarantee Systemgenerated

 Without interest buy-down only Systemgenerated

 With loan guarantee only Systemgenerated

 With both interest buy-down and loan 

guarantee

Systemgenerated

Preferred interest (greater than prime)

 Without interest buy-down or loan guarantee Systemgenerated

 Without interest buy-down only Systemgenerated

 With loan guarantee only System-
State Financing

Page 6

generated

 With both interest buy-down and loan 

guarantee

Systemgenerated

Total Systemgenerated

Systemgenerated

(System will generate an error message if total number of loans does not match number reported in row 

A of the table in Section A.1.)

b) Enter the dollar value of both partnership loans and revolving loans. The number of 

loans in each category will automatically populate based on the table in 3(a). Report 

each loan in only one category.

Type of Loan Number of Loans Dollar Value of Loans

Revolving loans System-generated $

Partnership loans System-generated $

Total System-generated System-generated

3. Interest Rates

a) Enter the lowest and highest interest rates among all loans made, including both 

revolving and partnership loans. For interest buy-downs, report the interest rate to 

which you bought the loan down:

Lowest: ______________%

Highest:______________%

b) Use the table below to calculate the average interest rate for all loans, including both 

revolving and partnership loans. Enter the sum of interest rates for all loans in Column 

A. The system will divide that amount by the number of loans made as previously 

reported and automatically populated in row A to calculate the average interest rate.

A B C

Sum of Interest 

Rates Number of Loans Made Average Interest Rate

System-generated System-generated
State Financing

Page 7

c) In the table below, enter the number of loans made at interest rates in each of the 

specified ranges. The total number of loans should match the number you reported in 

row A of the table in Section A.1. above.

Number of Loans Made at Interest Rates of --

Total Number 

0- of Loans

2.0%

2.1–

4.0%

4.1–

6.0%

6.1–

8.0%

8.1-

10%

10.1-

12%

12.1-

14% 14+%

Systemgenerated

(System will generate an error message if total number of loans does not match number automatically 

populated as the total based on previous reported data.)

4. Types and Dollar Amounts of AT Financed

Use the table below to provide information on the types of devices or services financed 

and the dollar value of loans made for each type of device or service. Report 

devices/services only once in a category per loan. For guidance on how to classify 

devices and services, and decision rules for devices and services that could be 

classified in more than one way, refer to the General Instructions. Because a single 

loan may pay for more than one device or service, the number of devices and services 

reported in this table may exceed the number of loans. However, the total dollar value 

of loans should be the same as reported previously in 3.b.

For large building access projects or similar activities with multiple devices in one AT 

category, the numbers reported should reflect a logical access grouping (e.g., a 

bathroom modification or exterior ramping of a house would be a home modification). 

Where an AT service (such as an evaluation) was part of a financial loan, include that 

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

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

If the loan is a refinance, and the AT purchased with previous loan has never been 

reported, you should reported the AT devices/services purchased with the previous loan 

as the AT associated with the refinance. (NOTE: If the refinance is of a previous loan 

and the AT purchased with the previous loan has been reported, the refinance should 

not be reported at all.).

Type of AT Device/Service

Number of Devices 

Financed

Dollar Value of 

Loans

Vision 

Hearing 

Speech communication

Learning, cognition, and 

developmental 

Mobility, seating and positioning 
State Financing

Page 8

Daily living 

Environmental adaptations

Vehicle modification and 

transportation 

Computers and related 

Recreation, sports, and leisure

Total System-generated $ System-generated

(System will generate an error message if total dollar value of loans does not match amount reported in 

the Total Dollar Value of Revolving Loans and Partnership Loans calculated in Item 3(b) above.)

6. Defaults

In the first cell below, enter the number of loans that were in default during this reporting 

period. A loan is in default after 120 days in which the borrower has not made the 

scheduled payment for the balance still owed; or at which time the organization 

administering the loan paid the lending institution the remaining agreed upon balance of 

loan. Do not count any payments that may have been made by the loan administering 

organization on behalf of the borrower during that 120-day period as payments made by 

the borrower. (Rescue payments do not count as borrower payments and the 120 day 

clock continues).

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

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

subtracting any funds that were recovered. It includes the amount that is unpaid on any 

loans in default and any loan guarantee payout amounts minus the amount of collateral 

recovered.
State Financing

Page 9

Number of Loans in Default Net Dollar Loss on Loans 

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

you will be able to recoup some of the net dollar loss associated with this default during 

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

loss until the next reporting period. This should only occur when loans went into default 

later in the current reporting period and you have not had sufficient time to sell or 

otherwise recoup some of the value of the collateral.

7. Additional Data for Title III funded AFP

This section collects additional data ONLY for financial loans that are part of a Title III 

funded Alternative Financing Program (AFP). By completing this section you will NOT 

need to submit these loans in the separate AFP Progress Report.

a) Range of Dollar Amounts of Loans Provided

In the table below, enter how many loans were made within the range of dollar 

amounts shown below. This is the dollar amount of the entire loan, not the dollar 

amount divided among different devices if more than one device was purchased.

(System will generate an error message if total number of loans does not match number reported in row A 

of the table in Section A.1.)

b) Highest and Lowest Loan Amounts

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

reporting period:

Highest $_________

Lowest $ _________

c) Classification of Consumers Receiving Assistance

Number and Percentage of Loans 

Made to Applicants in the Amount of

 $1,000 

or 

Less

$1,001 

to 

$5,000

$5,001 

to 

$10,000

$10,001 

to 

$15,000

$15,001 

to 

$20,000

$20,001 

to 

$25,000

$25,001 

to 

$50,000

$50,001 

or More

Total

Number 

of 

loans

Systemgenerated

Percent 

of 

Loans

SystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated
State Financing

Page 10

Use the tables below to report data about the consumers who received loans from your 

Title III funded alternative financing program (AFP) during this reporting period. The 

data should be provided only for the direct user of the AT, not the individual to whom the 

loan was provided (in some cases these are the same person, but often they are not).

A direct user is an individual that uses an AT Device or Service that provides a direct 

benefit or impact to the individual. A secondary user or beneficiary is a person who 

benefits from the user having an AT Device or Service. For example, if a family acquired 

a modified van for two children that are wheelchair users, both children would be 

considered direct users, but the parents of the children would be considered the 

secondary users or beneficiaries. Although a secondary user or beneficiary may benefit 

from the direct user having an AT device or service, for the data below, you must report 

on the direct user only.

i) Gender

Enter the total number of direct users of AT benefiting from a loan for a device or 

service by gender - female or male. If multiple persons are direct users of the AT 

provided by a single loan, the gender for each direct user should be reported.

Gender of Direct User(s) Number

Female

Male

Total System-generated

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

ii) Age

Enter the total number of direct users of AT benefiting from a loan for a device or 

service by the age range distribution. If multiple persons are direct users of the 

AT provided by a single loan, the age for each direct user should be reported. 

Programs should report the actual age of the direct user(s) at the time the loan 

was made.

Age of Direct Users of AT Number 

0-9

10-17

18-29

30-39

40-49

50-59

60-69

70-79 

80+

Total System-generated

(Total must equal total in i. above.)
State Financing

Page 11

iii) Type of Disability

In this section, report on the AT user’s abilities affected by the AT they are 

purchasing during this reporting period. An AT user may be affected in more 

than one area, therefore the data reported for each user may reflect multiple 

areas or “Type of Abilities” affected.

Type of Ability Number

Seeing

Hearing

Talking/communicating

Getting around/mobility

Handling objects, reaching

Learning new information

Remembering

Interacting with others/socializing

Total System-generated

(Total must be equal to or greater than i. and ii. The number of areas affected may exceed the 

totals reported for age and gender.)

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 distribution; (3) 

other (specify)

2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and 

Services and Number for whom Performance Measure Data are Collected

In this table, report the number of individuals who acquired AT devices and services 

through this activity, by the Rural Urban Continuum Code (RUCC) for the county in 

which they reside. For guidance on how to find a county’s RUCC, please see the 

“General Instructions.”

Of the recipients of AT devices and service, identify the number for whom performance 

measure data can be reported. This may be all of the recipients or may be fewer if the 

Statewide AT Program is administering a program (using external funding to 

purchase/provide the AT) on behalf of an entity that has responsibility for providing AT 

devices and services. The performance measure data questions are not answerable by 

such entities. While the number of individuals served by such programs should be 

reported here and in #3 below, performance measure data should not be collected for 

those individuals.
State Financing

Page 12

County of Residence

Individuals 

Served

A.Metro (RUCC 1-3)

B.Non-Metro (RUCC 4-9)

C. Total Served

i Systemgenerated

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 Systemgenerated

(ii = i minus excluded number D)

If a number is reported in D you must provide a description of the reason the individuals 

are excluded from the performance measure: 

_________________________________________

3. Types and Dollar Amounts of AT Funded

Use the table below to provide information on the number of devices or services funded 

and the amount of funding provided, by type of AT device/service. Report each device 

or service in only one category. For guidance on how to classify devices and services, 

and decision rules for devices and services that could be classified in more than one 

way, refer to the General Instructions.

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

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

one home modification). Where funding was provided for an AT service (such as an 

evaluation), include that dollar amount in the appropriate AT category associated with 

the service (e.g., an audiological evaluation would go in the “hearing” category).

Type of AT Device/Service

Number of Devices 

Funded

Value of AT 

Provided

Vision $

Hearing $

Speech communication $

Learning, cognition, and developmental $

Mobility, seating and positioning equipment $

Daily living $

Environmental adaptations $

Vehicle modification and transportation $
State Financing

Page 13

Computers and related $

Recreation, sports, and leisure $

Total System-generated $ System-generated

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

Cost

1. Overview of Activities Performed

How many activities that allow consumers to obtain AT at reduced cost were included in 

your approved State Plan? – enter number. Which of the following best describes this 

state financing activity? Drop-down box: (1) cooperative buying activity; (2) other 

(specify)

2. Geographic Distribution and Number of Individuals Served

In this table, report the number of individuals who acquired AT devices and services 

through this activity, by the Rural Urban Continuum Code (RUCC) for the county in 

which they reside. For guidance on how to find a county’s RUCC, please see the 

“General Instructions.”

Of the recipients of AT devices and service, identify the number for whom performance 

measure data can be reported. This may be all of the recipients or may be fewer if the 

recipients of the cost savings are entities that have responsibility for providing AT 

devices and services regardless of cost. The performance measure data questions are 

not answerable by such entities. While the number of individuals served by such 

programs should be reported here and in #3 below, performance measure data should 

not be collected for those individuals. See the instructions “Who To Collect Data” for 

more information.

County of Residence

Number of 

Individuals 

Served

A.Metro (RUCC 1-3)

B.Non-Metro (RUCC 4-9)

C. Total Served

i Systemgenerated

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 Systemgenerated

(ii = i minus excluded number D.)
State Financing

Page 14

If a number is reported in D you must provide a description of the reason the individuals 

are excluded from the performance measure: 

_________________________________________

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

Use the table below to provide information on the number of devices or services 

provided to consumers and the savings to consumers resulting from this activity, by type 

of AT device or service. Report each device or service in only one category. For 

guidance on how to classify devices and services, and decision rules for devices and 

services that could be classified in more than one way, refer to the General Instructions.

For each type of AT device, enter the total estimated current purchase price of the 

devices and the total amount for which devices were sold. The system will calculate the 

resulting savings to consumers. Use the Manufacturer’s Suggested Retail Price 

(MSRP) to determine the current purchase price of the device. If you are unable to find 

the exact price for a particular item, use the value of a comparable device. Using 

estimates is acceptable when exact pricing is not available. You may need to identify 

multiple similar devices and average to estimate a MSRP. If the device was given 

away, use a sale price of zero in your calculations.

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

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

one home modification). Where funding was provided for an AT service (such as an 

evaluation), include that dollar amount in the appropriate AT category associated with 

the service (e.g., an audiological evaluation would go in the “hearing” category).

Type of AT

Device/Service

Number 

Provided

Total 

Estimated 

Current Retail 

Purchase Price

Total Price 

for Which 

Devices 

Were Sold

Savings

to Consumers

Vision Systemgenerated

Hearing Systemgenerated

Speech communication Systemgenerated

Learning, cognition, and 

developmental 

Systemgenerated

Mobility, seating and 

positioning 

Systemgenerated

Daily living Systemgenerated

Environmental adaptations Systemgenerated
State Financing

Page 15

Vehicle modification and 

transportation 

Systemgenerated

Computers and related Systemgenerated

Recreation, sports, and 

leisure 

Systemgenerated

Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

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. If you reported 

Title III AFP financial loan data in section A, you MUST provide an anecdote here for 

that activity. You may provide an additional anecdote if you reported an activity in 

section B and/or C. Each narrative is limited to 1000 words for purposes of the MIS 

data system. While you can enter words past this limit, they will not be displayed when 

data is pulled from MIS.

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

(Narrative item #1)

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

(Narrative item #2)

E. Performance Measures

State financing activities are covered by the Acquisition Performance Measure. To 

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

from consumers. Use data collected from consumers to complete the table below. 

Refer to the “General Instructions” for guidance on how to categorize the primary 

purpose for which AT devices/service are needed.

The total number of customers from whom data is reported must equal the sum of the 

number of individuals to whom financial loans were made (as reported in Section A.1.A)

and the number of individuals served by other state financing activities who are included 

in performance measures (as reported in Sections B.2.E.ii and C.2.E.ii).
State Financing

Page 16

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 Systemgenerated

SystemgeneratedSystemgenerated

5. None of the above (d)

6. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

7. Nonrespondent (d)

8. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

9. Performance on this 

measure 

SystemgeneratedSystemgeneratedSystemgenerated

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.)
State Financing

Page 17

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)
Page 18

Reuse

Outline

Overview of Activities Performed 

A. Number of recipients of reused devices

B. Device exchange activities

C. Device Reassignment/Refurbishment and Repair Activities

D. Open-ended loans

E. Anecdote

F. Performance measures

G. Customer satisfaction

H. Notes

Section 4f requirement: the number, type, estimated value, and scope of assistive 

technology devices exchanged, repaired, recycled, or reutilized (including redistributed 

through device sales, loans, rentals, or donations) through the device reutilization 

activities, and an analysis of the individuals with disabilities that have benefited from 

the device reutilization activities

Device reuse includes device exchange activities and device 

reassignment/refurbishment and repair activities. It also includes open-ended device 

loans in which the borrower can keep the device for as long as it is needed, because 

these loans are considered a form of “acquisition.”

Device exchange activities are those in which devices are listed in a “want ad”-type 

posting and consumers can contact and arrange to obtain the device (either by 

purchasing it or obtaining it for free) from the current owner. Exchange activities do not 

involve warehousing inventory and do not include sanitation or refurbishing of used 

devices. In some cases, a Statewide AT Program serves as an intermediary directly 

involved in making this exchange; in others the consumer and current owner make this 

exchange without the involvement of the Statewide AT Program. Data on device 

exchange may be difficult to gather if your program does not serve as an intermediary 

directly involved in the exchange.

Device reassignment/refurbishment and repair activities are those in which devices are 

accepted (usually by donation) into an inventory; are sanitized and/or refurbished as 

needed; and then offered for sale, loan, rental, or give away to consumers as 

redistributed products. Repair activities are those in which device(s) are repaired for an 

individual (without the ownership of the device changing hands) which prevent the 

owner from needing to purchase a device.

Open-ended device loans are when a device borrower can keep a device (usually a 

reused device) for as long as required to meet a particular need. Open-ended device 

loans are generally distinguishable from short-term device loans by the length of the 
Reuse

Page 19

typical loan period. Open-ended loans are generally long term with the device placed 

with a consumer on a permanent basis but done via loan rather than ownership 

transferring to the consumer.

Overview of Activities Performed

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

reuse activities? Check yes or leave unchecked.

A. Number of Recipients of Reused Devices

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

reassignment/refurbishment and repair activities, and open-ended loans. In the table 

below, report on the number of individuals who receive devices through a reuse

program. Recipients should be reported only once, even if they receive multiple devices 

during this reporting period. (The multiple devices will be reported in subsequent 

sections.) There are two reasons that individuals may be excluded from the 

Performance Measures –

(1) Given the fact that many device exchange programs have little direct contact with 

device buyers, it may not be possible to collect information sufficient to include 

these individuals in the performance measures. Therefore, you can choose to 

exclude exchange device recipients from performance measure data reporting 

simply because you are unable to or it is too difficult to collect such data. Exchange 

is the only activity that offers this opt-out option for performance measure data.

(2) Some entities that have an obligation to provide AT may provide it via reuse. For 

example, a school has an obligation to provide AT devices identified in an IEP and 

the school may obtain the device through the reuse program. In this case, the 

performance measure questions are not answerable by the school because the 

issues of affordability or availability are not allowable reasons to limit access to AT 

that has been identified as necessary by the IEP team. You should exclude from 

the performance measures device recipients who acquire reused devices under 

these circumstances.

Activity

Number of Individuals 

Receiving a Device from 

Activity

A. Device exchange

B. Reassignment/refurbishment and Repair

C. Open-ended loans

D. Total Served i System-generated

Performance Measure

E. Device Exchange - Excluded from Performance 

Measure 

F. Reassignment/refurbishment and Repair and Open- Mandatory explanation
Reuse

Page 20

ended loans – Excluded from Performance Measure 

because AT is provided to or on behalf of an entity that 

has an obligation to provide the AT such as schools 

under IDEA or VR agencies/clients)

G. Number of Individuals Included in Performance 

Measures ii System-generated

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

If a number is reported in F you must provide a description of the reason the individuals 

are excluded from the performance measure: 

_________________________________________

B. Device Exchange Activities

Enter the total number of devices exchanged (listed by one individual/entity and 

obtained by another) during the reporting period, by AT type. For each type of AT 

device, enter the total estimated current purchase price of the devices and the total 

amount for which the devices were exchanged. To report a device as “exchanged” you 

must have documentation of the price for which it was sold or exchanged. Use the 

Manufacturer’s Suggested Retail Price (MSRP) to determine the current purchase price 

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

value of a comparable device. You many need to identify multiple similar products and 

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

information is not available. If the device was given away, use a sale price of zero in 

your calculations. The system will calculate the resulting savings to consumers in the 

last column.

Type of AT Device Number of 

Devices 

Exchanged

Total 

Estimated 

Current 

Purchase Price

Total Price 

for Which 

Device(s) 

Were 

Exchanged

Savings to 

Consumers

Vision Systemgenerated

Hearing Systemgenerated

Speech communication Systemgenerated

Learning, cognition &

developmental 

Systemgenerated

Mobility, seating and 

positioning 

Systemgenerated

Daily living Systemgenerated
Reuse

Page 21

Environmental adaptations Systemgenerated

Vehicle modification &

transportation 

Systemgenerated

Computers and related Systemgenerated

Recreation, sports and 

leisure

Systemgenerated

Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

C. Device Reassignment/Refurbishment and Repair Activities

Enter the total number of devices reassigned/refurbished/repaired and acquired by an 

end user during the reporting period, by type. For each type of AT device acquired, 

enter the total estimated current purchase price of the devices and the total price for 

which the devices were sold. The system will calculate the resulting savings to 

consumers. Use the MSRP to determine the current purchase price of the device. If 

you are unable to find the exact price for a particular item, use the value of a 

comparable device. You many need to identify multiple similar products and average to 

identify a MSRP. Using estimates is acceptable when exact pricing information is not 

available. If the device was given away, use a sale price of zero in your calculations.

Type of AT Device

Number of 

Devices 

Reassigned/ 

Refurbished & 

Repaired

Total 

Estimated

Current 

Purchase 

Price

Total 

Price for 

Which 

Devices 

Were Sold

Savings to 

Consumers

Vision Systemgenerated

Hearing Systemgenerated

Speech communication Systemgenerated

Learning, cognition and 

developmental 

Systemgenerated

Mobility, seating & 

positioning 

Systemgenerated

Daily living Systemgenerated

Environmental adaptations Systemgenerated
Reuse

Page 22

Vehicle modification &

transportation 

Systemgenerated

Computers and related Systemgenerated

Recreation, sports and 

leisure

Systemgenerated

Total System-generated Systemgenerated

SystemgeneratedSystemgenerated

D. Open Ended Loans

Enter the total number of devices loaned in open-ended loans during the reporting 

period, by type. For each AT type, enter the total estimated current purchase price of 

the devices and the cost to the consumer for the loan. If there was no charge to the 

consumer, use a zero as the cost to the consumer. The system will calculate the 

resulting savings to consumers. Use the MSRP as the current purchase price of the 

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

price. You may need to identify multiple similar products and average for the MSRP. 

Using estimates is acceptable when exact pricing information is not available. NOTE: 

Open-ended loans are reported only once in the reporting period the loan is made; not 

in subsequent years even if the loan is still open.

Type of AT Device

Number of 

Devices on 

Long-Term 

Loan

Total 

Estimated 

Current 

Purchase 

Price

Cost to 

Consumer 

for the 

Loan 

Savings to 

Consumers

Vision Systemgenerated

Hearing Systemgenerated

Speech communication Systemgenerated

Learning, cognition and 

developmental 

Systemgenerated

Mobility, seating and 

positioning 

Systemgenerated

Daily living Systemgenerated

Environmental adaptations Systemgenerated

Vehicle modification & System-
Reuse

Page 23

transportation generated

Computers and related Systemgenerated

Recreation, sports and 

leisure

Systemgenerated

Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

E. Anecdote

Provide ONE anecdote about an individual who benefited from a reuse activity. For 

guidance on information to include in the anecdote, please see the “General 

Instructions.” If you have a picture to accompany the narrative you submit, please 

check the box provided. Each narrative is limited to 1000 words for purposes of the MIS 

data system. While you can enter words past this limit, they will not be displayed when 

data is pulled from MIS.

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

(Narrative item #1)

F. Performance Measures

Device reuse activities are covered by the Acquisition Performance Measure. To report 

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

consumers to complete the tables below. Refer to the “General Instructions” for 

guidance on how to categorize the primary purpose for which AT devices/services are 

needed.

Performance measure for exchange, reassignment/refurbishment and repair and openended 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 Total

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 
Reuse

Page 24

system was too complex or 

wait time was too long (n,d)

4. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

5. None of the above (d)

6. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

7. Nonrespondent (d)

8. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

9. Performance on this 

measure 

SystemgeneratedSystemgeneratedSystemgenerated

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

Nonrespondents are included in the denominator for calculation of performance. (System will generate an 

error message if total reported in column at far right does not equal total of Sections A.ii )

G. Customer Satisfaction

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

the table below for all customers served by device reuse activities.

Customer Rating of Services Number of Customers Percent

Highly satisfied System-generated

Satisfied System-generated

Satisfied somewhat System-generated

Not at all satisfied System-generated

Nonrespondent System-generated

Total surveyed System-generated

Response rate System-generated

(System will generate an error message if total surveyed is not equal to the number of individuals who 

acquired a reused device reported in Section A(i).

H. Notes

Describe any unique issues that may affect your data in this section. If you have a 

device exchange program, please describe your data collection method, any challenges 

with collecting these data, and plans for overcoming those challenges.

(Narrative item)
Page 25

Device Loans

Outline

Overview of Activities Performed 

A. Short-Term Device Loans by Type of Purpose

B. Number of Device Loans by Type of Borrower

C. Length of short-term device loans 

D. Types of devices loaned

E. Anecdote

F. Performance measures

G. Customer satisfaction

H. Notes

Section 4f requirement: the number, type, and length of time of loans of assistive 

technology devices provided to individuals with disabilities, employers, public 

agencies, or public accommodations through the device loan program...and an 

analysis of individuals with disabilities who have benefited from the device loan 

program

Statewide AT programs provide short-term loans of AT devices to individuals or entities. 

The purpose of the loan may be to assist in decision making, to serve as a loaner while 

the consumer is waiting for device repair or funding, to provide an accommodation on a 

short-term basis for a time-limited event, for training, self-education or other 

professional development activities. Loans for the purpose of decision-making should 

be included in the access performance measure. Loans for all other purposes: 

providing a device during repair or while waiting for funding, providing an 

accommodation for a time-limited event, and training or personnel development should 

be included in the acquisition performance measure.

In this section, report only on short-term loans in which devices are borrowed for a 

limited or prescribed amount of time for one of the four purposes described in Section A. 

Based on national data, typical short-term loan periods range from between 30 and 45 

calendar days. Device loans for significantly longer periods should be reviewed as 

possible open-ended loans, especially when the loan structure is done as an alternative 

to device ownership transferring to the consumer. Open-ended device loans, in which 

the device borrower can keep the device for as long as it is needed, should be reported

under “Device Reuse.”

Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting short-term 

device loans? check yes or leave unchecked.
Device Loans

Page 26

A. Short-Term Device Loans by Type of Purpose

In this section, report the total number of short-term device loans made during the 

reporting period. A loan (counted as one) is defined as an occasion on which a device 

or devices were borrowed by an individual/entity who will use the device for one of the 

following purposes –

1) To make a decision (one decision) based on data, judgments, and other relevant 

information gained from trial use of the device in a natural environment with technical 

assistance available, upon request, from someone who has technical expertise 

related to the device(s) borrowed.

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

decision is involved).

3) To provide an accommodation for a time-limited event such as a meeting or 

situation such as a hospital stay (no decision is involved). Device loans that provide 

access to education, employment, or community living for as long as the individual 

has the device out on loan should be reported as an open-ended loan.

4) To conduct training, self-education, or other professional development activities

(no decision involved).

The number of short-term device loans will equal the number of borrowers reported in 

B, as each loan will be classified by the type of individual or entity that borrows. The 

number of loans will NOT necessarily equal the number of devices borrowed as 

reported in D as there may be multiple devices borrowed within a single loan.

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

If the same individual or entity borrows devices on more than one occasion

during the reporting period, count each occasion as a separate loan if a 

separate decision will be made

If the same individual or entity borrows devices on more than one occasion

during the reporting period and a single decision will be made, count that as 

one device loan.

If you extend the period of a short-term device loan, count that as a separate 

loan only if (1) the extension is for a different purpose than the original loan 

and a separate decision will be made; or (2) the borrower is an “intermediary” 

borrowing on behalf of others (e.g., a teacher), and the intermediary is 

requesting an extension to accommodate a second “end user” (i.e., an 

individual other than the one for whom the loan was initially made) and a 

second decision will be made.
Device Loans

Page 27

Report the number of short-term device loans made by primary purpose of the loan. 

Count each loan in only one category, even if the loan included multiple devices. If at 

least one device included in the loan was obtained for the purpose of decision-making, 

report the loan in the first row.

Primary Purpose of Short-Term Device Loan

Number of 

Loans

Assist in decision making (device trial or evaluation) Access 

Performance 

Measure

Serve as loaner during device repair or while waiting for funding Acquisition 

Performance 

Measure

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

event/situation

Acquisition 

Performance 

Measure

Conduct training, self-education or other professional development 

activity

Acquisition 

Performance

Measure

Total i. Systemgenerated

B. Number of Device Loans by Type of Borrower

In this section, report the number of device loans by type of borrowers, by type of 

individual or entity. The total number of device borrowers should equal the total number 

of short-term device loans reported by primary purpose in Item A. You must be able to 

categorize borrowers to report them in this table as there is no option for “unable to 

categorize” or “other”.

Type of Individual or Entity Number of Device Borrowers

Individuals with disabilities

Family members, guardians, and authorized 

representatives

Representatives of Education 

Representatives of Employment 

Representatives of Health, allied health, and 

rehabilitation 

Representatives of Community Living

Representatives of Technology

Total System-generated
Device Loans

Page 28

C. Length of Short-Term Device Loans

What is the length of a short-term device loan, as established by your statewide AT 

program’s policies not including extensions? Please report the length in calendar days. 

If your policy/procedures establish a range, use the midpoint.

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

D. Types of Devices Loaned

Enter the number of devices that were loaned, by type of device. For guidance on how 

to categorize devices, refer to the “General Instructions.” The number of devices loaned 

may exceed the number of loans reported above in Item A, since a loan may include 

more than one device.

Type of AT Device Number

Vision 

Hearing 

Speech communication

Learning, cognition, and developmental 

Mobility, seating and positioning 

Daily living 

Environmental adaptations

Vehicle modification and transportation 

Computers and related 

Recreation, sports, and leisure

Total System-generated

E. Anecdote

Provide ONE anecdote about an individual who benefited from a device loan activity. 

For guidance on information to include in the anecdote, please see the “General 

Instructions.” If you have a picture to accompany the narrative you submit, please

check the box provided. Each narrative is limited to 1000 words for purposes of the MIS 

data system. While you can enter words past this limit, they will not be displayed when 

data is pulled from MIS.

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

(Narrative item #1)
Device Loans

Page 29

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 data from all customers who obtained device loans for the purpose of decisionmaking (i.e., the number reported in Item B. Row A). That data will be used to complete 

the table below. Refer to the “General Instructions” for guidance on how to categorize 

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

Response

Primary Purpose for Which AT is Needed Total

Education Employment

Community 

Living

1. Decided that an AT 

device/service will 

meet needs (n,d)

2. Decided that an AT 

device/service will not 

meet needs (n,d)

3. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

4. Have not made a 

decision (d)

5. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

6. Nonrespondent 

(d, if > 35%)

7. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

8. Performance on 

this measure

SystemgeneratedSystemgeneratedSystemgenerated

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

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

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

reported in Item A, Row 1.).

G. Acquisition Performance Measures

Device loan activities for the purpose of providing loaner equipment during device repair 

or while waiting for funding, for providing an accommodation for a time-limited event, 

and for professional development activities are covered by the Acquisition Performance 

Measure. To report data for this measure, statewide AT programs will collect follow-up 

information from consumers to complete the table below. Refer to the “General 

Instructions” for guidance on how to categorize the primary purpose for which AT 

devices/services are needed. The number of borrowers reported must equal the total 

number reported in rows 2, 3, and 4 of Section A.
Device Loans

Page 30

Response

Primary Purpose for Which AT is 

Needed

Education Employment Total

Community 

Living

1. Could only afford to borrow 

the AT through the statewide 

AT program (n,d)

2. AT was only available 

through the statewide AT 

program (n,d)

3. AT was available to borrow 

from other programs, but the 

system was too complex or the 

wait time was too long (n,d)

4. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

5. None of the above (d)

6. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

7. Nonrespondent (d if > 35%)

8. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

9. Performance on this 

measure 

SystemgeneratedSystemgeneratedSystemgenerated

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

Nonrespondents are included in the denominator for calculation of performance. (System will generate an 

error message if total reported in column at far right does not equal total of Sections A rows 2 + 3 + 4.)

H. Customer Satisfaction

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

the table below for all customers served by device loans (total in A.i.)

Customer Rating of Services Number of Customers Percent

Highly satisfied System-generated

Satisfied System-generated

Satisfied somewhat System-generated

Not at all satisfied System-generated

Nonrespondent System-generated

Total System-generated

Response rate System-generated
Device Loans

Page 31

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 32

Device Demonstrations

Outline

Overview of Activities Performed 

A. Number of Device Demonstrations by Device Type

B. Types of participants

C. Number of referrals 

D. Anecdote

E. Performance measures

F. Customer satisfaction

G. Notes

Section 4f requirement: the number and type of device demonstrations and referrals 

provided and an analysis of individuals with disabilities who have benefited from the 

demonstrations and referrals

Device demonstrations compare the features and benefits of a particular AT device or 

category of devices for an individual or small group of individuals. The purpose of a 

device demonstration is to enable an individual to make an informed choice.

Whenever possible, the participant should be shown a variety of devices. Device 

demonstrations should not be confused with training activities at which devices are 

demonstrated. Training activities are instructional events designed to increase 

knowledge, skills, and competencies, generally for larger audiences. Training can also 

be targeted/focused instruction for an individual or small group (such as in-depth 

training for an individual consumer on a specific AT device). This targeted training is for 

skill development whereas device demonstrations are for decision-making purposes.

Device demonstrations also should not be confused with public awareness activities at 

which devices are demonstrated. The key difference is that device demonstrations are 

intended to enable an individual to make an informed choice rather than merely making 

him or her aware of a variety of AT.

In a device demonstration for an individual, guided experience with the device(s) is 

provided to the participant with the assistance of someone who has technical expertise 

related to the device(s). This expert may be in the same location as the participant or 

may assist the participant through Internet or distance learning mechanism that 

provides real-time, effective communication to deliver the necessary device exploration. 

(See the instructions for further clarification and examples.)

As noted in the instructions for this section, a device demonstration referral is provision 

of information about a specific source where the customer may obtain additional 

information or services related to AT. A referral must provide a consumer with 

information on how to contact that source directly. Referrals may be made to funding 

sources, service providers, vendors, or repair services. Do not include referrals to other 

components of your statewide AT program. Report only on referrals that result from 
Device Demonstrations

Page 33

demonstration activities, not referrals made through an information and assistance 

activities.

Overview of Activities Performed

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

demonstrations? Check yes or leave unchecked.

A. Number of Device Demonstrations by Device Type

In this section, report the number of device demonstrations by type of device/service 

demonstrated during this reporting period. For guidance on how to categorize devices 

and services, refer to the “General Instructions.” A device demonstration (counted as 

one) is defined as an occasion in which one or more devices within a category are 

demonstrated to an individual or small group who will make a decision (one decision) 

based on data, judgments, comparisons and other relevant information gained from the 

interaction with the equipment and demonstrator. The number of device 

demonstrations will NOT necessarily equal the number of demonstration participants 

reported in B as there may be multiple participants in a demonstration even though only 

one decision will be made.

Type of AT Device/Service

Number of Demonstrations 

of this Type of AT 

Device/Service

Vision 

Hearing 

Speech communication 

Learning, cognition, and developmental 

Mobility, seating and positioning 

Daily living 

Environmental adaptations

Vehicle modification and transportation 

Computers and related 

Recreation, sports, and leisure

Total System-generated

B. Types of Participants

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

demonstrations, by type of participant. Include all individuals participating in 

demonstrations, not just those who are making a decision (or for whom a decision is 

being made). For guidance on how to categorize participants, refer to the “General 

Instructions.” You must be able to categorize participants to report them in this table as 

there is no option for “unable to categorize” or “other”.
Device Demonstrations

Page 34

Type of Participant

Number of Participants in 

Device Demonstrations

Individuals with disabilities

Family members, guardians, and authorized 

representatives

Representatives of Education 

Representatives of Employment 

Representatives of Health, allied health, and 

rehabilitation 

Representatives of Community Living 

Representatives of Technology

Total System-generated

C. Number of Referrals

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

participants in a demonstration may receive more than one referral, or may not be 

referred at all, the number of referrals may be greater or less than the number of 

participants and number of demonstrations. Do not include referrals to other 

components of your statewide AT program.

Type of Entity Number of Referrals

Funding source (non-AT program)

Service provider

Vendor

Repair service

Others

D. Anecdote

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

activity. For guidance on information to include in the anecdote, see “General 

Instructions.” If you have a picture to accompany the narrative you submit, please check 

the box provided. Each narrative is limited to 1000 words for purposes of the MIS data 

system. While you can enter words past this limit, they will not be displayed when data 

is pulled from MIS.

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

(Narrative item #1)
Device Demonstrations

Page 35

E. Performance Measures

Device demonstrations are covered by the Performance Measure 1 (access). To collect 

data for this measure, statewide AT programs will collect data from the identified 

decision-maker who participated in demonstrations (one per demonstration as reported 

in Item A). That data will be used to complete the table below. Refer to the “General 

Instructions” for guidance on how to categorize the primary purpose for which AT 

devices/services are needed.

Response

Primary Purpose for Which AT is Needed

Education Employment

Community 

Living Total

1. Decided that an AT 

device/service will meet 

needs (n,d)

2. Decided that an AT 

device/service will not meet 

needs (n,d)

3. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

4. Have not made a decision 

(d)

5. Subtotal Systemgenerated

SystemgeneratedSystemgenerated

6. Nonrespondent (d)

7. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

8. Performance on this 

measure 

SystemgeneratedSystemgeneratedSystemgenerated

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
Device Demonstrations

Page 36

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 37

Overall Acquisition Performance Measure (auto-populated)

The acquisition performance measure is the sum of State Financing, Reuse and Shortterm Device Loan (purposes of providing device during repair, while waiting for funding 

and short-term accommodation) performance measure data.

Overall Access Performance Measure (auto-populated) 

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

Response

Primary Purpose for Which At is 

Needed Total

Education Employment

Community 

Living

1. Decided that an AT System- System- System- SystemResponse

Primary Purpose for Which AT is Needed

Total Education Employment Community 

Living

1. Could only afford the 

AT through the statewide 

AT program 

SystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

2. AT was only available 

through the statewide AT 

program 

SystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

3. AT was available 

through other programs, 

but the system was too 

complex or the wait time 

was too long 

SystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

4. Subtotal Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

5. None of the above Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

6. Subtotal Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

7. Nonrespondent Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

8. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

9. Performance on this 

measure 

SystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

10. RSA Performance 

Target

11. Met or Not Met
Training

Page 38

device/service will meet needs generated generated generated generated

2. Decided that an AT 

device/service will not meet 

needs 

SystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

3. Subtotal Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

4. Have not made a decision Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

5. Subtotal Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

6. Nonrespondent Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

7. Total Systemgenerated

SystemgeneratedSystemgeneratedSystemgenerated

8. Performance on this 

measure

SystemgeneratedSystemgeneratedSystemgeneratedSystemgenerated

9. RSA Performance Target 

10. Met/Not Met
Training

Page 39

Training

Outline

Overview of Activities Performed

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

distribution 

B. Training topics

C. Description of training activities

D. Notes

Section 4f requirements: Training

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

training...(such as individuals with disabilities, parents, educators, employers, 

providers of employment services, health care workers, counselors, other service 

providers, or vendors)”

2. ”the topics of such training”

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

participated in the training.”

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

requirement that statewide AT programs provide training and technical assistance to 

assist students with disabilities who receive transition services under IDEA and 

adults with disabilities maintaining or transitioning to community living. Section e 

also requires that at least 5% of the money spent on State Leadership activities be 

used for transition activities.

The AT Act of 1998, as amended provides a combined description of training and 

technical assistance (see Section-Specific Definitions). Following is guidance on what 

activities to report in this section and how to distinguish training activities from public 

awareness or technical assistance activities. Report each activity only once, in the 

appropriate section.

This section of the reporting form also collects information on training activities that are 

related to transition. Information on technical assistance activities related to transition 

should be reported in that section of the form. Reminder- each Statewide AT Program 

must report on at least one transition activity related to school transition (e.g., secondary 

school to post-school) AND one transition activity related to community living transition 

(e.g. congregate living to community living). The activity reported may be either a 

training event or a technical assistance initiative.

Training activities are instructional events, usually planned in advance for a specific 

purpose or audiences, which are designed to increase participants’ knowledge, skills, 

and competencies regarding AT. Such events can be delivered to large or small 

groups, in-person, or via telecommunications or other distance education mechanisms. 

In general, participants in training can be individually identified and could complete an 

evaluation of the training. Examples of training include classes, workshops, and 
Training

Page 40

presentations that have a goal of increasing skills, knowledge, and competency, as 

opposed to training intended only to increase general awareness of AT.

Distinguishing Training Activities from Public Awareness Activities

Training activities have more depth and breadth than public awareness activities and 

are focused on skill building and competency development. If the purpose of a training 

session is to create awareness, the training session should be counted under public 

awareness, not under training. In general, participants in training can be individually 

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

individually.

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

troubleshooting problems with devices should be reported under Public Awareness as 

“Information and Assistance.”

Distinguishing Training from Technical Assistance

Training is designed to teach, present, or guide individuals in order to impart knowledge, 

skills, and competencies. Technical assistance is focused on providing extensive 

assistance to state or local agencies or other entities (rather than individuals) and 

generally involves problem solving to achieve a mutually agreed-upon goal. Technical 

assistance may involve multiple contacts and interactions over an extended period of 

time.

In some cases, training may be a component of technical assistance. Training that is 

provided as part of technical assistance can be reported here, but only if the training 

was one of several technical assistance activities. If training was the only technical 

assistance activity, it can be reported as either training or technical assistance, but not 

both.

Overview of Activities Performed

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

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

Distribution

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

derived from other training event records. Use “unable to categorize” when no 

data can be obtained on type of participant.

Type of Participant Number

Individuals with disabilities

Family members, guardians, and authorized 
Training

Page 41

representatives

Representative of Education 

Representative of Employment. 

Representative of Health, allied health, and 

rehabilitation 

Representative of Community Living 

Representative of Technology

Unable to Categorize

Total

2. Enter the number of individuals who participated in training, by the Rural Urban 

Continuum Code (RUCC) of the participant’s county. For a consumer, you 

determine the RUCC by the county in which he or she resides. For a 

representative, you determine the RUCC by the county in which they generally 

provide services. Training participants for whom you cannot determine a county 

are counted in “Unknown.” For additional guidance on the RUCC, refer to the 

“General Instructions.”

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

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

Page 42

B. Training Topics

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

Training topics are organized into categories:

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

2. AT funding, policy and practice, which includes subcategories of common topics 

in this category and space other related AT topics.

3. Information Technology/Telecommunications which includes subcategories of 

related uses of information technology and telecommunications products. For 

participants in this training topic, you will need to collect a performance 

measure, see Data Collection Instrument IT/Telecommunication Training 

Performance Measure.

4. Combination of AT products and services, AT funding, policy and practice and/or 

IT/Telecommunications. (Use this category only when absolutely necessary.)

5. Transition, including transition from school to work or postsecondary education 

and transition to community living. (Use this category for ALL transition activities 

even if they could be reported as AT Products/Services, AT Funding/Policy, etc.)

Primary Topic of Training 

Number of 

Training 

Participants

1. AT Products/Services 

Training focused on AT: such as instruction to increase skills and

competency in using AT, and integrating AT into different settings 

2.AT Funding/Policy/ Practice

Training focused on funding sources and related laws, policies, and 

procedures required to implement and deliver access to AT 

devices/services and related.

3.Information Technology/Telecommunication Access

Training focused on accessible information technology and 

telecommunications including web access, software accessibility, 

procurement of accessible IT and telecommunications, etc.

A 

performance 

measure

must be 

collected for 

these 

training 

participants

4 Combination of any/all of the above -- AT Products/Services, AT 

Funding/ Policy/Practice and/or IT/Telecommunications Access
Training

Page 43

5.Transition 

Training focused on education transition (school to work or postsecondary education and early intervention (birth to 3) to school 

aged (3 -21) and community transition (maintaining or transitioning 

to community living). (Note: A number must be reported here 

unless transition technical assistance activity/activities are

reported.)

Total System 

generated

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

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.

Narrative item- Each narrative is limited to 1000 words for purposes of 

the MIS data system. While you can enter words past this limit, they will 

not be displayed when data is pulled from MIS.

2. Briefly describe a training activity related to transition conducted during this 

reporting period. Note who conducted the training (e.g., type of expertise of 

staff) and characteristics of the audience (including number that attended). In 

one sentence, describe the topic, content, and/or approach of the training. In 

one sentence, summarize the positive result or intended impact of the training. 

Do not include overall descriptions of conferences held, unless the conference 

had a unique purpose and outcome. This section must be completed unless 

you are reporting transition technical assistance activities. If this section 

is completed, an associated number of training participants must be 

reported in Section B Row 5.

Narrative item- Each narrative is limited to 1000 words for purposes of 

the MIS data system. While you can enter words past this limit, they will 

not be displayed when data is pulled from MIS.
Training

Page 44

D. IT/Telecommunications Training Performance Measure

Outcome/result from IT/Telecommunication Training Received Number

IT and telecommunications procurement or development policies, 

procedures, or practices will be improved or better implemented to 

ensure accessibility.(n,d)

Training or technical assistance will be developed or implemented to 

ensure accessibility of IT and telecommunications. (n,d)

No known outcome at this time. (d) 

Nonrespondent (d) 

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

Systemgenerated

Performance Measure Percentage

Systemgenerated

RSA Target Percentage

Met/Not Met 

E. Notes

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

particular topics or audiences were emphasized or were not included during this 

reporting period).

(Narrative item)
Page 45

Technical Assistance

Outline

Overview of Activities Performed

A. Frequency and nature of technical assistance

B. Description of technical assistance activities

C. Notes

Section 4f requirements: 

Technical Assistance 

“The frequency of provision and nature of technical assistance provided to State and 

local agencies and other entities.”

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

requirement that AT programs provide training and technical assistance to assist 

students with disabilities who receive transition services under IDEA and adults with 

disabilities maintaining or transitioning to community living. Section e also requires 

that at least 5% of the money spent on State Leadership activities be used for 

transition activities.

The AT Act of 1998, as amended provides a combined description of training and 

technical assistance (see “General Definitions”). Additional descriptions of technical 

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

assistance activities from public awareness activities and training activities.

Technical Assistance (TA) is defined as direct problem-solving service provided by 

Statewide AT Program staff to assist programs and agencies in improving their 

services, management, policies, and/or outcomes. TA may be provided in person, by 

electronic media such as telephone, video, or e-mail, and by other means. The 

following are examples of technical assistance: needs assessment, program planning 

or development, curriculum or materials development, administrative or management 

consultation, program evaluation and site reviews of external organizations, and policy 

development.

Mandatory transition activities that are technical assistance are reported in this section; 

mandatory transition activities that are training are reported in the training section. 

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.
Technical Assistance

Page 46

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.
Technical Assistance

Page 47

Program or agency receiving technical assistance Percentage of all TA

Education

Employment

Health, Allied Health, Rehabilitation

Community Living

Technology (Information Technology, Telecommunications, 

Assistive Technology)

Total Must equal 100%

B. Description of Technical Assistance Activities

In Item 1 below, describe an innovative or high-impact technical assistance activity that 

is not related to transition. For this item, choose a technical assistance activity that had 

an outcome. In Item 2 below, describe a technical assistance activity that is related to 

transition. The transition technical assistance activity is not required to have an 

outcome.

1. Describe in detail one innovative or high-impact technical assistance activity

conducted during this reporting period. Note who provided the technical assistance 

(e.g., type of expertise of staff) and characteristics of the recipient agency. In two 

sentences: (1) describe the topic, content, and/or approach of the technical 

assistance; and (2) summarize the positive result or impact of the technical 

assistance.

Narrative item- Each narrative is limited to 1000 words for purposes of the MIS 

data system. While you can enter words past this limit, they will not be displayed 

when data is pulled from MIS.

2. Briefly describe one technical assistance activity related to transition conducted 

during this reporting period. Note who provided the technical assistance (e.g., type

of expertise of staff) and characteristics of the recipient agency. In two sentences: 

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

summarize the positive result or impact of the technical assistance. NOTE: This

section must be completed unless a transition training activity is reported.

Narrative item- Each narrative is limited to 1000 words for purposes of the MIS 

data system. While you can enter words past this limit, they will not be displayed 

when data is pulled from MIS.
Technical Assistance

Page 48

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 49

Public Awareness and Information and Assistance

Outline

Overview of Activities Performed

A. Public awareness activities

B. Information and Assistance

C. Notes

Section 4f requirement: “the number of individuals assisted through the public 

awareness activities and statewide information and referral system”. 

Public awareness activities are designed to reach large numbers of people, including 

activities such as public service announcements, radio talk’s shows and news reports, 

newspaper stories and columns, newsletters, brochures, and public forums. Actual 

numbers of information recipients are often difficult to know for certain, but should be 

reported when known, and in other cases estimated as accurately as possible. Public 

awareness activities should be reported, as accurately as possible, in Part A of this 

section.

Information and assistance includes provision of information and supports to individuals 

and provision of referrals to other entities. All of these activities may be provided in 

person, over the telephone, via email, or other effective communication mechanisms.

Distinguishing Information and Assistance from Device Demonstration Referral

In this section, report only on referrals resulting from information dissemination 

activities, such as calls to a 1-800 number or e-mails. Referrals resulting from device 

demonstrations should be reported under device demonstrations.

Distinguishing Public Awareness from Training

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

public awareness or training. Include presentations made for the purpose of general 

awareness under public awareness. Do not include training sessions with the intended 

outcome of participants applying new knowledge or skills in addressing AT 

device/service issues (which should be reported under training).

Overview of Activities Performed

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

reported.

A. Public Awareness Activities

In this section report on public awareness activities intended to reach a wide 

audience. In the table below enter the known or estimated number of individuals 
Public Awareness and Information and Assistance

Page 50

reached during the reporting period by each type of public awareness activity. 

Activities must be reported in one of the categories provided (there is no “other” 

category). The categories provided should enable reported of all major public 

awareness activities. Presentations reported in this section are for the purpose of 

general awareness. Training sessions with the intended outcome of participants 

applying new knowledge or skills in addressing AT device/service issues should be 

reported as a training activity. (NOTE: Purchasing promotional items is not 

allowable under OMB Circular direction and as such should not be reported in this 

section.)

Public Awareness Activity Estimated Number of Individuals Reached

Newsletters

Other print materials

Listservs/blogs/social media

Internet information

Other electronic media

PSA - radio/TV/other media

Presentations/expos/conferences

Total

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
Public Awareness and Information and Assistance

Page 51

Types of Recipients of 

Information and Assistance

AT Device/ 

Service

AT Funding/ 

Policy/Practice Total

Individuals with disabilities Systemgenerated

Family members, guardians, 

and authorized representatives

Systemgenerated

Representative of Education Systemgenerated

Representative of Employment Systemgenerated

Representative of Health, 

Allied Health, and 

Rehabilitation 

Systemgenerated

Representative of Community 

Living 

Systemgenerated

Representative of Technology Systemgenerated

Unable to Categorize Systemgenerated

Total Systemgenerated

SystemgeneratedSystemgenerated

C. Notes

Describe any unique issues with your data in this section.

(Narrative item)
Data Collection Instrument

Page 52

State Improvement Outcomes

Outline

Overview of Activities Performed

A. State improvement outcomes

B. State improvement outcome (if second one reported)

It is understood and expected that AT Programs will coordinate and collaborate with 

other public and private entities in terms of receiving referrals, sharing information, 

serving on advisory board, etc. and will provide technical assistance to a variety of 

agencies and entities throughout the reporting period. Outcomes of state 

improvements initiatives must result in policy, practice or procedure improvements 

beyond those associated with or already reported in previous state-level and state 

leadership coordination and collaboration sections.

Section 4f requirements: “the outcomes of any improvement initiatives carried out by 

the State as a result of activities funded under this section, including a description of 

any written policies, practices, and procedures that the State has developed and 

implemented regarding access to, provision of, and funding for, assistive technology 

devices, and assistive technology services, in the contexts of education, health care, 

employment, community living, and information technology and telecommunications, 

including e-government.” 

Overview of Activities Performed

State improvement outcomes are not required. You may report up to two MAJOR state 

improvement outcomes for this reporting period. How many will you be reporting? (For 

example, you may have worked with your state Information Technology Office to 

implement an Executive Order related to web accessibility or may have worked with 

your Medicaid office to streamline procedures for obtaining wheeled mobility devices.) 

-- enter zero, 1 or 2

A. State Improvement Outcomes

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

1. In one or two sentences, describe the outcome. Be as specific as possible 

about exactly what changed during this reporting period as a result of the AT 

program’s initiative. (Narrative field)

2. In one or two sentences, describe the written policies, practices, and procedures 

that have been developed and implemented as a result of the AT program’s 

initiative. Include information about how to obtain the full documents, such as a 

Web site address or e-mail address of a contact person, but do not include the 

full documents here. (If there are no written policies, practices, and procedures, 

explain why.) (Narrative field)
Additional and Leveraged Funds

Page 53

3. What was the primary area of impact for this state improvement outcome? 

Drop-down box: Education – Employment -- Health, Allied Health, Rehabilitation

-- Community Living -- Technology (Information Technology, 

Telecommunications, and Assistive Technology).

B State Improvement Outcome

If you have a second MAJOR outcome to report, this section will need to be completed

with items 1 through 3 above.

Additional and Leveraged Funds

Outline

Overview of Activities Performed 

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

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

C. Notes

Section 4f requirement: “(x) the source of leveraged funding or other contributed 

resources, including resources provided through subcontracts or other collaborative 

resource-sharing agreements, from and with public and private entities to carry out 

State activities described in subsection (e)(3)(B)(iii), the number of individuals served 

with the contributed resources for which information is not reported under clauses (i) 

through (ix) or clause (xi) or (xii), and other outcomes accomplished as a result of 

such activities carried out with the contributed resources”

Overview of Activities Performed

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

unchecked).

In this section, provide information on funding that has been leveraged to support 

statewide AT Program activities. Report only actual dollars leveraged; do NOT report inkind contributions. The additional and leveraged funding reported in this section is NOT 

necessarily considered program income under federal guidelines.

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

Statewide AT Programs often establish partnerships and leverage funds to support 

state implementation of required AT Act activities as described in your State Plan. 

These funds should be reported by entering the sources and amounts of non-AT Act 

funds that you received during this reporting period to support your State Plan activities. 

Report each source and amount in the reporting period that it was received, even if not 

all of the funds were expended in that reporting period. Do not report AFP endowments 

or matching funds. Identify which state level or leadership activity the funds were 

allocated to support. If funds were received to support more than one activity, report an 
Additional and Leveraged Funds

Page 54

amount for each activity according to funding allocations. The number of individuals 

served by those funds or other outcomes should have already been reported in the 

appropriate previous sections.

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

Ο Federal

Ο Public/State Agency

Ο State Appropriations

Ο Private

Ο State Financing Ο Training

Ο Reuse Ο Technical 

Assistance

Ο Demonstration Ο Public 

Awareness, I&A

Ο Device Loan

option to repeat row data 

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

reported in other activity sections)

Statewide AT Programs may also leverage funds to support activities that are 

authorized by the AT Act but not included in a State Plan. For example, a state may 

administer external funding for an activity that could be reported as Other State 

Financing, but they choose not to include that data in the State Financing section. If an 

activity is approved as part of your state plan and has associated leveraged funding, it 

should NOT be reported here but should be reported in the previous section A. This 

section is limited to only non-State Plan approved activities with leveraged funding that 

do not have information on individuals served or other outcome data reported in 

previous sections.

Funds used to support these activities should be reported by entering the sources and 

amounts of non-AT Act funds that you received during this reporting period. Report 

each source and amount in the reporting period that it was received, even if not all of 

the funds were expended in that reporting period. Do not report AFP endowments or 

matching funds. Identify which activities those funds were allocated to support. Report 

the number of individuals served by each funding source identified; or describe other 

outcomes if the “individuals served” is not an appropriate outcome measure.

Fund Source Amount Use of Funds – select 

one

Individuals Served 

or

Other Outcome

Ο Federal 

Ο Public/State Agency

Ο State Appropriations

Ο Private

Ο State Financing 

Ο Reuse 

Ο Demonstration 

Ο Device Loan 

Ο Training

Ο Technical Assistance

Ο Public Awareness, 

I&A

(enter the number 

individuals served 

or describe the 

outcome)
Additional and Leveraged Funds

Page 55

option to repeat row 

data 

C. Notes

Describe any unique issues with your data in this section (e.g., the reason why you 

were unable to report the number of individuals served with additional or leveraged 

funds).

(Narrative item)
Data Collection Instrument

Page 56

Data Collection Instrument

Access Performance Measure

TO BE COMPLETED BY PROGRAM STAFF ID 

(optional) ____________

 Services provided:

 Device demonstration

 OR

 Device loan (decision-making purpose)

 Date service delivery was completed: __________

 Date this form was received: ____________________

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

name of statewide AT program or its subcontractor). We need this information to provide 

high quality services and to meet the requirements for receiving federal funding.

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

service is related to:

(Please mark only one answer.)

 Education—participating in any type of educational program

 Community living—carrying out daily activities, participating in community 

activities, using community services, or living independently

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

employment training program, vocational rehabilitation program, or other program

related to employment

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

represent) able to make after your device demonstration or device loan?

(Please mark only one answer.)

_____ Decided that an AT device or service will meet my needs (or the needs of 

someone I represent).

_____ Decided that an AT device or service will not meet my needs (or the needs of 

someone I represent).

_____ Have not made a decision.

Paperwork Burden Statement

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

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

information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes 

per response, including the time to review instructions, search existing data resources, gather the data needed, and 

complete and review the information collection. If you have any comments concerning the accuracy of the time 

estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 

20202. If you have any comments or concerns regarding the status of your individual submission of this form, write 

directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac 

Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.
Data Collection Instrument

Page 57

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 highquality services and to meet the requirements for receiving federal funding.

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

service is related to:

(Please mark only one answer.)

 Education—participating in any type of educational program

 Community living—carrying out daily activities, participating in community 

activities, using community services, or living independently

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

employment training program, vocational rehabilitation program, or other program

related to employment

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

(Please mark only one answer.)

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

other programs.)

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

don't qualify for other programs, the AT is not covered by other funding sources 

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

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

complex or the wait time was too long.

_____ None of the above

Paperwork Burden Statement

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

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

information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes 

per response, including the time to review instructions, search existing data resources, gather the data needed, and 

complete and review the information collection. If you have any comments concerning the accuracy of the time 

estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 

20202. If you have any comments or concerns regarding the status of your individual submission of this form, write 

directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac 

Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.
Data Collection Instrument

Page 58

Data Collection Instrument

Acquisition Performance Measure (Device Loan)

TO BE COMPLETED BY PROGRAM STAFF  ID (optional)

____________

 Short-term device loan purposes:

 Providing loaner equipment during device repair or while waiting for funding

 Providing an accommodation for a time-limited event 

 Conducting training, self-education or other professional development 

activity 

 Date service delivery was completed: __________

 Date this form was received: ____________________

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

statewide AT program or its subcontractor). We need this information to provide highquality services and to meet the requirements for receiving federal funding.

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

service is related to:

(Please mark only one answer.)

 Education—participating in any type of educational program

 Community living—carrying out daily activities, participating in community 

activities, using community services, or living independently

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

employment training program, vocational rehabilitation program, or other program

related to employment

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

(Please mark only one answer.)

_____ I could only afford to borrow the AT through this program. (I could not afford to 

rent or borrow it through other programs.)

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

there is no other rental or device loan program available; or the specific device I 

needed is not loaned by other programs.)

_____ The AT was available to borrow from other programs, but the system was too 

complex or the wait time was too long. (I couldn’t borrow the device in a timely 

manner.)

_____ None of the above

Paperwork Burden Statement

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

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

information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes 

per response, including the time to review instructions, search existing data resources, gather the data needed, and 

complete and review the information collection. If you have any comments concerning the accuracy of the time 

estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 

20202. If you have any comments or concerns regarding the status of your individual submission of this form, write 

directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac 

Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.
Data Collection Instrument

Page 59

Data Collection Instrument

IT/Telecommunications Training Performance Measure

TO BE COMPLETED BY PROGRAM STAFF  ID (optional)

____________

 IT/Telecom Training Session

 Date training was provided: __________

 Date this form was received: ____________________

Please answer the following question about the training you participated in provided by 

(insert name of statewide AT program or its subcontractor). We need this information to 

provide high-quality services and to meet the requirements for receiving federal funding.

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

Information Technology/Telecommunications Access?

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

_____ IT and telecommunications (web, software, etc.) procurement or development 

policies, procedures, or practices will be improved or better implemented to 

ensure accessibility

 _____ Training will be developed/implemented to ensure accessibility of websites, 

software or other IT and telecommunications (web, software, etc.)

_____ Outcome is unknown at this time.

Paperwork Burden Statement

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

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

information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes 

per response, including the time to review instructions, search existing data resources, gather the data needed, and 

complete and review the information collection. If you have any comments concerning the accuracy of the time 

estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 

20202. If you have any comments or concerns regarding the status of your individual submission of this form, write 

directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac 

Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.
Survey Instrument Consumer Satisfaction

Page 60

Survey Instrument

Customer Satisfaction

TO BE COMPLETED BY AT PROGRAM STAFF ID 

(optional) __________

 Services provided:

 Device demonstration

 Device loan

 “State financing” services—including financial loan, assistance in 

accessing funds for AT devices/services, assistance in obtaining AT 

devices and services at reduced cost or free, or other related services

 Device reuse— received an AT device through a device exchange, 

reassignment/refurbish or repair or open-ended loan program

 Date service delivery was completed: __________

 Date this form was received: ____________________

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

received?

(Check one.)

_____ Highly satisfied

_____ Satisfied

_____ Satisfied somewhat

_____ Not at all satisfied

Paperwork Burden Statement

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

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

information is 1820-0572. The time required to complete this information collection is estimated to average 2 minutes 

per response, including the time to review instructions, search existing data resources, gather the data needed, and 

complete and review the information collection. If you have any comments concerning the accuracy of the time 

estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 

20202. If you have any comments or concerns regarding the status of your individual submission of this form, write 

directly to Mr. Robert Groenendaal, Rehabilitation Services Administration, U.S. Department of Education, Potomac 

Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.