Association of Assistive Technology Act Programs (ATAP)

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APPENDIX E – Data Collection Instrument

Rehabilitation Services Administration

Annual Report for

State Grant for Assistive Technology Programs

Public Reporting Burden

OMB # 1820-0572

Expires: 01/31/2010

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 collection is 1820-0572.The time required to complete this form is estimatedto 456 hours 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(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of the Chief Financial Officer, U.S. Department of Education, 600 Independence Avenue SW, Washington, D.C. 20202-4248.

This document was prepared by RTI International and the Association of Assistive Technology Act Programs
under grants from the U.S. Department of Education
Grant Nos. H224B030001 and H224B060002

 

 

Instructions for completion of this form and relevant definitions are contained in a separate document, “ Instruction Manual and Definitions for the Annual Report for the State Grant for Assistive Technology Program.” Throughout the reporting form, terms for which a definition is available are indicated with an asterisk (*). Please refer to the “Instructions” for those definitions.

General Information

1. General Information
Statewide AT Program
State and Program Title
Lead Agency
Agency name Mailing address City State Zip code Phone Fax Program URL Program E-mail Program toll-free number Program TTY number Implementing Entity Check here if not applicable. If applicable, complete Items 14–24. Name of implementing entity Mailing address City State Zip code Phone Fax Program URL Program E-mail Program toll-free number Program TTY number Program director and other contacts Name of Program Director at Lead Agency (last, first) Title Phone E-mail Name of Program Director at Implementing Entity (last, first) – If applicable Title Phone E-mail Person responsible for completing this form If program director, check here. If different, complete Items 29–32. Name (last, first) Title Phone E-mail Date form completed (mm/dd/yy) Certifying representative Name (last, first) Title Phone E-mail

State Financing

Outline General information Financial loan programs* Loan applications Income of applicants to whom loans were made Loan type Interest rates Types and dollar amounts of AT financed Defaults* State financing activities* that provide consumers with resources and services that result in the acquisition of AT devices and services General information Geographic Distribution, Number of Individuals Who Acquired AT Devices and Services and Number for whom Performance Measure Data are Collected Types and dollar amounts of AT funded Additional activities State financing activities* that allow consumers to obtain AT at reduced cost General information Geographic Distribution and Number of Individuals Served Savings to consumers, by type of AT device/service Additional activities Anecdote Performance measures Customer satisfaction 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” funds* with non-AT Act dollars, administering cooperative buying programs,* administering telecommunications distribution programs,* administering non-financial loan programs that provide home modifications,* and other activities designed to provide consumers with resources and services that result in the acquisition of AT devices and services.

• General Information

Did your statewide AT program conduct any state financing activities* during the reporting period?

Drop-down box: (1) yes; (2) no, statewide AT program exercised state flexibility;* (3) no, statewide AT program claimed comparability;* (4) no, statewide AT program is developing an activity not yet implemented (include feasibility studies* here)

(Respondents who choose “1” will receive balance of section.)

(If “2,” “3,” or “4” to Item 1) The state financing section of the reporting form includes the subsections listed below. If you would like to view a read-only version of the entire state financing section, or any of the subsections, please check the appropriate box(es). If, after reviewing the read-only version, you decide to enter data in any part of the state financing section, you will need to change your response in Item 1 to “Yes.”

□ View entire state financing section

□ View subsection—Financial loan programs

□ View subsection— State financing activities that provide consumers with resources and services that result in the acquisition of AT devices and services

□ View subsection—State financing activities that allow consumers to obtain AT at reduced cost

Financial Loan Programs*

Did the statewide AT program conduct a financial loan program* during the reporting period? (A financial loan program* is a program that provides loans for purchase of AT devices and services, for which the statewide AT program can report the number of applications received, approved, and rejected; the default rate*; the range and average interest rate; and the range and average income of approved applicants. Do not report Access to Telework funds* here; report that activity in Section C.

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will receive balance of section.)

• 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.

For guidance on how to classify the applicant’s area of residence as metro or non-metro, please see the “General Instructions.”

Number of Applications	Area of Residence		Total
	Metro RUCC 1-3	Non-Metro RUCC 4-9
Approved—loan made			System-generated
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)			System-generated
Rejected			System-generated
Total	System-generated	System-generated	System-generated

• 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.

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

Lowest: $______________

Highest: $______________

• 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 Aof the table in Section B, Item 1above 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

• 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 1above. 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 $20,000	$20,001 to $25,000	$25,001 to $30,000	$30,001 to $35,000	$35,001 or More
Number of loans							System-generated
Percentage of loans	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated	System-generated

(System will generate an error message if total number of loans does not match number reported in row Aof the table in Section B, Item 1above.)

• 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		System-generated
Loan guarantee* (no special interest rate)		System-generated
Low interest (prime or less)*
Without interest buy-down* or loan guarantee*		System-generated
With interest buy-down* only		System-generated
With loan guarantee* only		System-generated
With both interest buy-down* and loan guarantee*		System-generated
Preferred interest (greater than prime)*
Without interest buy-down* or loan guarantee*		System-generated
With interest buy-down* only		System-generated
With loan guarantee* only		System-generated
With both interest buy-down* and loan guarantee*		System-generated
Other (specify)		System-generated
Total	System-generated	System-generated

(System will generate an error message if total number of loans does not match number reported in row A of the table in Section B, Item 1above.)

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

• Interest Rates

• 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: ______________%

• 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

• 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 B, Item 1above.

Number of Loans Made at Interest Rates of								Total Number of Loans
0-2.0%	2.1–4.0%	4.1–6.0%	6.1–8.0%	8.1-10%	10.1-12%	12.1-14%	14+%
								System-generated

(System will generate an error message if total number of loans does not match number automatically populated as the total based on previous reported data.)

• Types and Dollar Amounts of AT Financed

Use the table below to provide information on the types of devices or services financed and the dollar value of loans made for each type of device or service. Report each device 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.

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. You previously reported a total dollar value of $ (system-generated).

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 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).

Type of AT Device/Service	Number of Devices Financed	Dollar Value of Loans
Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Other (specify)
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.)

• Defaults* and Net Losses for Revolving and Guaranteed Financial Loans

The default rate* in the following tables is reported only for revolving and guaranty loans, those for which the loan administering organization can incur a financial loss in the case of default.

Number of Loans in Default	Number of Active Loans	Percentage of Loans in Default
		System-generated

b. In the table below, enter the net dollar loss on defaulted loans to determine the default rate. The default rate* is the net dollar loss on loans divided by the total dollar value of active 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. Total dollar value of active loans means the unpaid percentage of guaranty or revolving loan balance the loan administering organization is responsible for paying in case of a default at the end of the reporting period of all active loans, no matter when they originated.

Net Dollar Loss on Loans	Total Dollar Value of Active Loans*	Default rate*
		System-generated

• State Financing Activities* that Provide Consumers with resources and services that result in the acquisition of AT devices and services

• General Information

a. Did the statewide AT program conduct another state financing activity that provides consumers with access to funds for the purchase of AT devices and services?

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will receive balance of section.)

Drop-down box: (1) Access to Telework Funds;* (2)“last resort” activity;* (3) financing for home modifications;* (4) telecommunications distribution;* (5) other (specify)

• 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. See the instructions “Who To Survey” for more information.

County of Residence	Number of Individuals Served	Number of Individuals Included inPerformance Measures (see required exclusion above)
A.Metro (RUCC 1-3)
B.Non-Metro (RUCC 4-9)
C. Total	i System-generated	ii

• 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		$
Computers and related		$
Recreation, sports, and leisure		$
Other (specify)		$
Total	System-generated	$ System-generated

• Additional Activities

Do you have additional activities to report in this section? If so, select “yes” and the system will repeat this section. If you select “no,” it will take you to the next section of the reporting form.

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will repeat this section.)

• State Financing Activities* that Allow Consumers to Obtain AT at Reduced Cost

• General Information

a. Did the statewide AT program conduct an activity that allows consumers to obtain AT at reduced cost?

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will receive balance of section.)

(If “Yes” to Item 1) Complete this section for that activity. If you have more than one activity to report, you will need to complete this section more than once. After you have completed your first entry, you will be given an opportunity to repeat this section in order to report additional activities.

Drop-down box: (1) cooperative buying activity; (2) other (specify)

• 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 Survey” for more information.

County of Residence	Number of Individuals Served	Number of Individuals Included in Performance Measures (see required exclusion above)
A.Metro (RUCC 1-3)
B.Non-Metro (RUCC 4-9)
C.Total	i. System-generated	ii

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

For large building access projects, the numbers reported should reflect a logical access grouping (e.g., a bathroom modification or exterior ramping of a house would each be one home modification). Where funding was provided for an AT service (such as an evaluation), include that dollar amount in the appropriate AT category associated with the service (e.g., an audiological evaluation would go in the “hearing” category).

Type of AT Device/Service	Number Provided	Total Estimated Current Retail Purchase Price	Total Price for Which Devices Were Sold	Savings to Consumers
Vision				System-generated
Hearing				System-generated
Speech communication				System-generated
Learning, cognition, and developmental				System-generated
Mobility, seating and positioning				System-generated
Daily living				System-generated
Environmental adaptations				System-generated
Vehicle modification and transportation				System-generated
Computers and related				System-generated
Recreation, sports, and leisure				System-generated
Other (specify)				System-generated
Total	System-generated	System-generated	System-generated	System-generated

• Additional Activities

Do you have additional activities to report in this section? If so, select “yes” and the system will repeat this section. If you select “no,” it will take you to the next section of the reporting form.

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will repeat this section.)

• Anecdote

Provide at least one anecdote about an individual who benefited from a state financing activity.* For guidance on information to include in the anecdote, please see the “General Instructions.”

(Narrative item)

• 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 from those surveys 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 surveyed should equal the sum of the following:

• the number of individuals to whom financial loans were made, as reported in Section B.1.A,

• the number of individuals served by other state financing activities who are included in performance measures as reported in Sections C.2.C.ii and D.2.C.ii.

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Could only afford the AT through the statewide AT program (n,d)
2. AT was only available through the statewide AT program (n,d)
3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d)
4. Subtotal	System-generated	System-generated	System-generated
5. None of the above (d)
6. Subtotal	System-generated	System-generated	System-generated
7. Nonrespondent (d)
8. Total	System-generated	System-generated	System-generated	System-generated
9. Performance on this measure	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator.Nonrespondents are included in the denominator for calculation of performance.(System will generate an error message if total reported in column at far right does not equal total reported in Sections B.1.A plus C.2.C.ii plus D.2.C.ii )

• 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 B.1.A plus C.2.C.i plus D.2.C.i )

• 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)

Reutilization

 

Outline General information Number of recipients of reutilized devices Device exchange activities Device Recycling/Refurbishment/Repair Activities Open-ended loans Anecdote Performance measures Customer satisfaction 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 reutilization includes device exchange activities* and device recycle/refurbish/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 repair, 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 recycle/refurbish/repair activities* are those in which devices are accepted (usually by donation) into an inventory; are repaired, sanitized, and/or refurbished as needed; and then offered for sale, loan, rental, or give away to consumers as recycled products. Repair of devices for an individual (without the ownership of the device changing hands) should be reported as device recycling.

• General Information

Drop-down box: (1) yes; (2) no, statewide AT program exercised state flexibility;*
(3) no, statewide AT program claimed comparability;* (4) no, statewide AT program is developing activity not yet implemented

(Respondents who choose “1” will receive balance of section.)

(If “2,” “3,” or “4” to Item 1) If you would like to view a read-only version of the entire device reutilization section please check the box below. If, after reviewing the read-only version, you decide to enter data in any part of the device reutilization section, you will need to change your response in Item 1 to “Yes.”

□ View device reutilization section.

• Number of Recipients of Reutilized Devices

In this table, report the number of recipients of devices through device exchange,* recycling/ refurbishment/repair activities,* and open-ended loans.

In the table below, report on the number of individuals who receive devices through a reutilization program. There are two reasons for which the number of individuals receiving devices through reutilization may not match the number included for Performance Measures.

Activity	Number of Individuals Receiving a Device from Activity	Number of Individuals Included in Performance Measure
Device exchange
Recycling/refurbishment/repair
Open-ended loans
Total	i System-generated	ii System generated

• Device Exchange Activities

Type of AT Device	Are devices in this category included in your listing?	Number of Devices Exchanged	Total Estimated Current Purchase Price	Total Price for Which Device(s) Were Exchanged	Savings to Consumers
Vision	Y/N				System-generated
Hearing	Y/N				System-generated
Speech communication	Y/N				System-generated
Learning, cognition and developmental	Y/N				System-generated
Mobility, seating and positioning	Y/N				System-generated
Daily living	Y/N				System-generated
Environmental adaptations	Y/N				System-generated
Vehicle modification and transportation	Y/N				System-generated
Computers and related	Y/N				System-generated
Recreation, sports and leisure	Y/N				System-generated
Other (specify)					System-generated
Total		System-generated	System-generated	System-generated	System-generated

• Device Recycling/Refurbishment/Repair Activities

Type of AT Device	Are devices in this category included in your program(s) ?	Number of Devices Recycled/ Refurbished/Repaired	Total Estimated Current Purchase Price	Total Price for Which Devices Were Sold	Savings to Consumers
Vision	Y/N				System-generated
Hearing	Y/N				System-generated
Speech communication	Y/N				System-generated
Learning, cognition and developmental	Y/N				System-generated
Mobility, seating and positioning	Y/N				System-generated
Daily living	Y/N				System-generated
Environmental adaptations	Y/N				System-generated
Vehicle modification and transportation	Y/N				System-generated
Computers and related	Y/N				System-generated
Recreation, sports and leisure	Y/N				System-generated
Other (specify)					System-generated
Total		System-generated	System-generated	System-generated	System-generated

• Open-Ended Loans

Type of AT Device	Are devices in this category included in your program(s) ?	Number of Devices on Long-Term Loan	Total Estimated Current Purchase Price	Cost to Consumer for the Loan	Savings to Consumers
Vision	Y/N				System-generated
Hearing	Y/N				System-generated
Speech communication	Y/N				System-generated
Learning, cognition and developmental	Y/N				System-generated
Mobility, seating and positioning	Y/N				System-generated
Daily living	Y/N				System-generated
Environmental adaptations	Y/N				System-generated
Vehicle modification and transportation	Y/N				System-generated
Computers and related	Y/N				System-generated
Recreation, sports and leisure	Y/N				System-generated
Other (specify)					System-generated
Total		System-generated	System-generated	System-generated	System-generated

• Anecdote

Provide at least one anecdote about an individual who benefited from a reutilization activity.* For guidance on information to include in the anecdote, please see the “General Instructions.”

(Narrative item)

• Performance Measures

Device reutilization activities* are covered by Performance Measure 2 (acquisition). To collect data for this measure, statewide AT programs will conduct customer surveys. Use data from those surveys 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, recycling/refurbishment/repair* and open-ended device loan activities should be reported in the table below. The number of customers surveyed should equal the total number reported in the second column (ii) of the table from Item B.

Response	Primary Purpose for Which AT is Needed			Total
	Education	Employment	Community Living
1. Could only afford the AT through the statewide AT program (n,d)
2. AT was only available through the statewide AT program (n,d)
3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d)
4. Subtotal	System-generated	System-generated	System-generated
5. None of the above (d)
6. Subtotal	System-generated	System-generated	System-generated
7. Nonrespondent (d)
8. Total	System-generated	System-generated	System-generated	System-generated
9. Performance on this measure	System-generated	System-generated	System-generated

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

Nonrespondents are included in the denominator for calculation of performance.

• Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the table below for all customers served by device reutilization activities.* Customer satisfaction surveys from sellers as well as buyers may be included here.

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 device reutilization reported in Item B(i).

• Notes

Describe any unique issues that may affect your data in this section (e.g., types of devices that are not reutilized because they are available from another source). 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)

 

Device Loans

 

Outline General information Short-Term Device Loans by Type of Purpose Number of Device Loans by Type of Borrower Length of short-term device loans Types of devices loaned Anecdote Performance measures Customer satisfaction 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, or for other purposes. “Other” purposes include: (1) self-education by a consumer for the purpose of later decision making (e.g., when the school year begins); (2) self-education by an intermediary (e.g., a teacher) whose purpose is to become familiar with the device; and (3) training. Only loans for the purpose of decision-making should be included in the performance measures.

In this section, report only on short-term loans in which devices are loaned for a limited or prescribed amount of time that is determined by your statewide AT program.

In this section, do not report open-ended device loans, in which the device borrower* can keep the device for as long as it is needed. Report these loans under “Device Reutilization.”

• General Information

Did your statewide AT program conduct short-term device loans* during the reporting period?

Drop-down box: (1) yes; (2) no, statewide AT program exercised state flexibility;*
(3) no, statewide AT program claimed comparability;* (4) statewide AT program is developing an activity not yet implemented

(Respondents who choose “1” will receive balance of section.)

(If “2,” “3,” or “4” to Item 1) If you would like to view a read-only version of the entire device loan section please check the box below. If, after reviewing the read-only version, you decide to enter data in any part of the device loan section, you will need to change your response in Item 1 to “Yes.”

□ View device loan section.

• 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 --

a) 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,

b) as a loaner during device repair or while waiting for funding (no decision is involved),

c) to provide an accommodation (no decision is involved), or

d) for some other purpose that does not involve a decision.

The number of short-term device loans will equal the number of borrowers reported in C, as each individual or entity borrowing will be classified by type. The number of loans will NOT necessarily equal the number of devices borrowed as reported in E 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 you extend the period of a short-term device loan, count that as a separate loan only if (1) the extension is for a different purpose than the original loan and a separate decision will be made; or (2) the borrower is an “intermediary” borrowing on behalf of others (e.g., a teacher), and the intermediary is requesting an extension to accommodate a second “end user” (i.e., an individual other than the one for whom the loan was initially made) and a second decision will be made.

 

Report the number of short-term device loans* made by primary purpose of the loan. Count each loan in only one category, even if the loan included multiple devices. If at least one device included in the loan was obtained for the purpose of decision-making, report the loan in Row A. Please see the instructions at the top of this section for what activities are included in “Other.”

Primary Purpose of Short-Term Device Loan	Number of Loans
A. Assist in decision making (device trial or evaluation)	Performance Measure
B. Serve as loaner during device repair or while waiting for funding
C. Provide an accommodation on a short-term basis
D. Other
Total	System-generated

• 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 in Item B. You should minimize your use of “other” to the greatest extent possible.

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
Others
Total	System-generated

 

• Length of Short-Term Device Loans

What is the usual length of a short-term device loan,* as established by your statewide AT program’s policies? If your program does not have an established policy, enter the average length of short-term device loans.* Please report the length in calendar days.

Usual length of short-term device loan,* in days: (Numeric field)

• Types of Devices Loaned

Enter the number of devices that were loaned, by type of device, and indicate whether devices in each category were included in your inventory. 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 B, since a loan may include more than one device.

Type of AT Device	Are devices in this category included in your loan pool?	Number
Vision	Y/N
Hearing	Y/N
Speech communication	Y/N
Learning, cognition, and developmental	Y/N
Mobility, seating and positioning	Y/N
Daily living	Y/N
Environmental adaptations	Y/N
Vehicle modification and transportation	Y/N
Computers and related	Y/N
Recreation, sports, and leisure	Y/N
Other (specify)	Y/N
Total		System-generated

• Anecdote

Provide at least 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.”

(Narrative item)

• Performance Measures

Device loan* activities are covered by the Performance Measure 1 (access). To collect data for this measure, statewide AT programs will conduct surveys of all customers who obtained device loans* for the purpose of decision-making (i.e., the number reported in Item B. Row A). Use data from those surveys 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	IT/ Tele-communi-cations
1. Decided that an AT device/service will meet needs (n,d)
2. Decided that an AT device/service will not meet needs (n,d)
3. Subtotal	System-generated	System-generated	System-generated	System-generated
4. Have not made a decision (d)
5. Subtotal	System-generated	System-generated	System-generated	System-generated
6. Nonrespondent (d, if > 35%)
7. Total	System-generated	System-generated	System-generated	System-generated	System-generated
8. Performance on this measure	System-generated	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator.Nonrespondents in excess of 35% are included in the denominator for calculation of performance.(System will generate an error message if total reported in column on far right does not equal total reported in Item B, Row A.)

• 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.*

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

• 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)

Device Demonstrations

 

Outline General information Number of Device Demonstrations by Device Type Types of participants Number of referrals Anecdote Performance measures Customer satisfaction 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.

Device demonstrations* also should not be confused with public awareness activities* at which devices are demonstrated. The key difference is that device demonstrations* are intended to enable an individual to make an informed choice rather than merely making him or her aware of a variety of AT.

In a device demonstration for an individual, guided experience with the device(s) is provided to the participant with the assistance of someone who has technical expertise related to the device(s). This expert may be in the same location as the participant or may assist the participant through Internet or distance learning mechanism that provides real-time, effective communication to deliver the necessary device exploration. (See the instructions for further clarification and examples.)

As noted in the instructions for this section, a device demonstration referral* is provision of information about a specific source where the customer may obtain additional information or services related to AT. A referral* must provide a consumer with information on how to contact that source directly. Referrals* may be made to funding sources, service providers, vendors, or repair services. Do not include referrals* to other components of your statewide AT program. Report only on referrals* that result from demonstration activities, not referrals made through an information and assistance activities.

• General Information

Did your statewide AT program conduct device demonstrations* during the reporting period?

Drop-down box: (1) yes; (2) no, statewide AT program exercised state flexibility;*
(3) no, statewide AT program claimed comparability;* (4) no, statewide AT program is developing activity not yet implemented

(Respondents who choose “1” will receive balance of section.)

(If “2,” “3,” or “4” to Item 1) If you would like to view a read-only version of the entire device demonstration section please check the box below. If, after reviewing the read-only version, you decide to enter data in any part of the device demonstrationsection, you will need to change your response in Item 1 to “Yes.”

□ View device demonstration section.

• 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 C 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
Other (specify)
Total	System-generated

• 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.” Note that the table includes a row for any participants whom you are unable to categorize.

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
Others
Total	System-generated

 

D. 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 will 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. You should minimize your use of “other” to the greatest extent possible.

Type of Entity	Number of Referrals
Funding source (non-AT program)
Service provider
Vendor
Repair service
Others

Provide at least one anecdote about an individual who benefited from a device demonstration activity.* For guidance on information to include in the anecdote, please see the “General Instructions.”

(Narrative item)

Device demonstrations are covered by the Performance Measure 1 (access). To collect data for this measure, statewide AT programs will conduct surveys of the identified decision-maker who participated in demonstrations (as reported in Item B). Use data from those surveys 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	IT/ Telecommuni-cations
1. Decided that an AT device/service will meet needs (n,d)
2. Decided that an AT device/service will not meet needs (n,d)
3. Subtotal	System-generated	System-generated	System-generated	System-generated
4. Have not made a decision (d)
5. Subtotal	System-generated	System-generated	System-generated	System-generated
6. Nonrespondent (d)
7. Total	System-generated	System-generated	System-generated	System-generated
8. Performance on this measure	System-generated	System-generated	System-generated	System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator.Nonrespondents are included in the denominator for calculation of performance.

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

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 demonstration.*

Customer Rating of Services	Number of Customers	Percent
Highly satisfied		System-generated
Satisfied		System-generated
Satisfied somewhat		System-generated
Not satisfied		System-generated
Nonrespondent		System-generated
Total	System-generated
Response rate	System-generated

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

H. 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)

Training

 

Outline   Training participants: Number and types of participants; geographical distribution Training topics Description of training activities Notes Section 4f requirements:Training1. “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 allocated for 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 audience, that are designed to increase participants’ knowledge, skills, and competencies regarding AT. Such events can be delivered to large or small groups, in-person, or via telecommunications or other distance education mechanisms. In general, participants in training* can be individually identified and could complete an evaluation of the training.* Examples of training* include classes, workshops, and presentations that have a goal of increasing skills, knowledge, and competency, as opposed to training intended only to increase general awareness of AT.

Distinguishing Training Activities from Public Awareness Activities

Training* activities have more depth and breadth than public awareness* activities and are focused on skill building and competency development. If the purpose of a training* session is to create awareness, the training session should be 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.

• Training Participants: Number and Types of Participants; Geographical Distribution

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

Type of Participant	Number
Individuals with disabilities
Family members, guardians, and authorized representatives
Representative of Education
Representative of Employment.
Representative of Health, allied health, and rehabilitation
Representative of Community Living
Representative of Technology
Others
Unable to categorize
Total

• Training Topics

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

Training* topics are organized into categories:

• AT products and services, which includes subcategories of AT types.
• AT funding, policy and practice, which includes subcategories of common topics in this category, and space to specify other topics.
• Information Technology/Telecommunications which includes subcategories of related uses of information technology and telecommunications products.
• Combination of AT products and services, AT funding, policy and practice and/or IT/Telecommunications. (Use this category only when absolutely necessary.)
• Transition, including transition from school to work or postsecondary education and transition to community living.
• Other training topics not included above. Please specify the topics.

Primary Topic of Training	Number of Training Participants
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.
4 Combination of any/all of the above -- AT Products/Services, AT Funding/ Policy/Practice and/or IT/Telecommunications Access
5.Transition Training focused on education transition (school to work or post-secondary education and Part C to Part B), community transition (institution to community living) and other transitions.
6 Other Topic (specify)
Total	System generated

• 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.

• 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 and outcome.

(Narrative item)

• 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.

(Narrative item)

• 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)

Technical Assistance

 

Outline Frequency and nature of technical assistance Description of technical assistance activities 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 allocated for 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 transition (e.g. congregate living to community living). The activity reported may be either a training event or a technical assistance initiative.

Distinguishing Technical Assistance from Public Awareness

Technical assistance* may include multiple contacts/interactions over an extended period of time. Less intensive support services, including single-contact requests for information or limited assistance, should be reported under public awareness.* For example, assisting an individual in troubleshooting problems with an AT device should be reported under public awareness.*

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 involves 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.

Distinguishing Technical Assistance from Information and Assistance

Technical assistance is provided to agencies or other organizations, not to individuals. Intensive support provided to an individual, for example assistance with a particular AT device or policy issue, is reported in Information and Assistance under Public Awareness.

A. Frequency and Nature of Technical Assistance

Complete this section for each major technical assistance* activity that you conducted. If you have more than one activity to report, you will need to complete this section more than once. After you have completed your first entry, you will be given an opportunity to repeat this section in order to report additional activities.

• Primary description of program or agency receiving technical assistance:* (check one):

Education

Employment

Health, Allied Health, Rehabilitation

Community Living

Technology (Information Technology, Telecommunications, Assistive Technology)

• For this technical assistance* activity, identify the policy expertise areas and product/service expertise areas that were addressed. If the technical assistance* activity included both policy and product/service expertise, select both.

Note that mandatory transition activities that are technical assistance activities are reported here under product/service expertise. Mandatory transition activities that are training activities are reported in the training section.

Radio buttons for “check all that apply”: (1) policy area; (2) product/service area

(If policy area) Identify the policy areas on which the technical assistance* focused. Choose all that apply.

Radio buttons: (1) ADA/504; (2) IDEA Part C; (3) IDEA Part B; (4) Section 508 and Section 255; (5) WIA/Rehabilitation Act/VR; (6) Medicaid; (7) Medicare; (8) Private insurance; (9) HAVA; (10) Older Americans Act; (11) SSI/SSDI/Work Incentives; (12) Olmstead (13) other (specify)

(If product/service area) Identify the product/service areas on which the technical assistance* focused. Choose all that apply.

Radio buttons: (1) Web accessibility; (2) accessible IT procurement; (3) AT purchasing (cost-effective options);(4) accessible voting systems; (5) AT eligibility determinations; (6) AT personnel development; (7) AT resource allocation; (8) AT service delivery options; (8) AT legislation/policy development; (9) specific AT device assistance; (10) transition–education; (11) transition–community living; (12) other (specify)

• Duration of technical assistance* during this reporting period:

Drop-down box: (1) less than 3 months; (2) 3 to 5 months; (3) 6 to 8 months;
(4) 9 to 12 months

• Approximate number of person hours expended by AT program staff to deliver the technical assistance:* (Numeric field)

• Do you have additional activities to report? If so, select “Yes” and the system will repeat this section. If you select “no,” it will take you to the next section of the reporting form.

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will repeat Items 1 through 5.)

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.

• 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)

• 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.*

(Narrative item)

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)

Public Awareness and Information and Assistance

 

 

Outline Public awareness activities Information and Assistance 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 talks 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 described, 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 mechanism

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).*

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

Public Awareness Activity	Estimated Number of Individuals Reached
Newsletters
Other print materials
Listservs
Internet information
PSA/radio/TV
Presentations/expos/conferences*
Other
Total

*Include only presentations made 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 counted as a training activity.

• 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, funding sources, or other related disability topics, or providing intensive assistance to individuals about AT products, devices, services, funding sources, or other related disability topics. This information may be provided in person, over the telephone, via email, or by some other means.

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. 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;
• Information and assistance for assistance in obtaining funding for AT; and

• Information and assistance for other related disability topics, such as: locating an interpreter; responding to questions about IDEA that are not AT related or assisting an individual access personal attendant services when no AT is involved.

To the extent practicable each unique request for information and assistance should be counted only once.

Types of Recipients of Information and Assistance	AT Device/ Service	AT Funding	Related Disability Topics	Total
Individuals with disabilities				System-generated
Family members, guardians, and authorized representatives				System-generated
Representative of Education				System-generated
Representative of Employment				System-generated
Representative of Health, Allied Health, and Rehabilitation				System-generated
Representative of Community Living				System-generated
Representative of Technology				System-generated
Others				System-generated
Total	System-generated	System-generated	System-generated	System-generated

• Notes

Describe any unique issues with your data in this section.

(Narrative item)

Coordination and Collaboration Activities

 

Outline State Level State Leadership Section 4f requirements: None Section (4)(e)(3)(B)(iii) requires that “The State shall coordinate activities described in paragraph (2) and this paragraph, among public and private entities that are responsible for policies, procedures, or funding for the provision of assistive technology devices and assistive technology services to individuals with disabilities, service providers, and others to improve access to assistive technology devices and assistive technology services for individuals with disabilities of all ages in the State.”

Provide the following information on your most significant coordination and collaboration as related to AT LEAST one state level activity and AT LEAST one state leadership activity. You may report on coordination and collaboration for every state level and state leadership activity if you so desire. If you have a Title III grant for an alternative financing program, do NOT report the mandatory roles of your community based organization or financial institution in operation of your financial loan program as coordination and collaboration. If you opted for comparability for one of the state-level activities, but work with the administering entity of the “Comparable Program” do NOT report such efforts under Coordination and Collaboration.

A. State Level

1. Identify the State Level activity for which you are reporting coordination and collaboration. (check one)

Ο State Financing

Ο Reutilization

Ο Demonstration

Ο Device Loan

2. What was the intended result of the coordination and collaboration? (check one)

Ο Establish a new program or service

Ο Expand a program or service to serve more individuals

(e.g. expand geographically or include a group not previously served)

Ο Eliminate duplicative programs or services

 

3. With whom did you primarily coordinate and collaborate? (check one entity type)

Ο Education

Ο Employment

Ο Health, Allied Health, Rehabilitation

Ο Community Living

Ο Technology (Information Technology, Telecommunications, Assistive Technology)

 

4. In three or four sentences, describe the collaboration and coordination including whether you achieved the result intended. (Narrative)

5. Do you want to report on coordination and collaboration for another State Level activity?

Yes/No (If yes, you will be given the opportunity to repeat this section but the already selected state level activity will not be available in the pick list in A.)

B. State Leadership

1. Identify the State Leadership activity for which you are reporting coordination and collaboration. (check one)

Ο Training

Ο Technical Assistance

Ο Public Awareness and Information and Assistance

 

2. What was the intended result of the coordination and collaboration? (check one)

Ο Establish a new program or service

Ο Expand a program or service to serve more individuals (e.g. expand geographically or include a group not previously served)

Ο Eliminate duplicative programs or services

 

3. With whom did you primarily coordinate and collaborate? (check one entity type)

Ο Education

Ο Employment

Ο Health, Allied Health, Rehabilitation

Ο Community Living

Ο Technology (Information Technology, Telecommunications, Assistive Technology)

 

4. In three or four sentences, describe the collaboration and coordination including whether you achieved the result intended. (Narrative)

 

5. Do you want to report on coordination and collaboration for another State Leadership activity?

Yes/No (If yes, you will be given the opportunity to repeat this section but the already selected state leadership activity will not be available in the pick list in A.)

State Improvement Outcomes

 

Outline General information State improvement outcomes 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 include 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.”

• General Information

Do you have state improvement outcomes* to report? (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.)

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will receive balance of section.)

(If “2” to Item 1) If you would like to view a read-only version of the entire “additional outcomes of state improvement initiatives” section please check the box below. If, after reviewing the read-only version, you decide to enter data in any part of the device reutilization section, you will need to change your response in Item 1 to “Yes.”

□ View “additional outcomes of state improvement initiatives” section

• State Improvement Outcomes

(If “Yes” to Item 1) Complete this section for the first state improvement outcome you want to report. If you have more than one outcome to report, you will need to complete this section more than once. After you have completed your first entry, you will be given an opportunity to repeat this section in order to report additional outcomes.

• 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)

• 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)

• Was the primary outcome of the state improvement initiative outcome* in a policy area? Drop-down box: (1) yes; (2) no

• (If yes) Identify the policy area in which the state improvement outcome* had its primary impact. Example of how to determine primary impact area: If an improvement initiative resulted in coverage of hearing aids for adults under Medicaid, Medicaid would be the policy impact area. Choose only one policy area for each outcome.

Drop-down box: (1) ADA/504; (2) IDEA Part C; (3) IDEA Part B; (4) Section 508 and Section 255; (5) WIA/Rehabilitation Act/VR; (6) Medicaid; (7) Medicare; (8) Private insurance; (9) HAVA; (10) Older Americans Act; (11) SSI/SSDI/Work Incentives; (12) Olmstead; (13) other (specify)

• What was the role of the statewide AT program in achieving the outcome (e.g., primary leader, partner, participant) and means (e.g., technical assistance) were used to achieve the outcome? (Narrative field)

• Do you have additional outcomes to report in this section? If so, select “yes” and the system will repeat this section. If you select “no,” it will take you to the next section of the reporting form.

Drop-down box: (1) yes; (2) no

(Respondents who choose “1” will repeat this section.)

Additional and Leveraged Funds

Outline Leveraged Funding for State Plan Activities (Previously Reported) Leveraged Funding for Activities Not in State Plan (not previously reported) 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”

In this section, provide information on funding that has been leveraged to support statewide AT Program activities. Report only actual dollars leveraged; do NOT report in-kind contributions. The additional and leveraged funding reported in this section is NOT necessarily considered program income under federal guidelines.

• Leveraged Funding for State Plan Activities (Previously Reported)

Statewide AT Programs often establish partnerships and leverage funds to support state implementation of required AT Act activities as described in your State Plan. These funds should be reported by entering the sources and amounts of non-AT Act funds that you received during this reporting period to support your State Plan activities. Report each source and amount in the reporting period that it was received, even if not all of the funds were expended in that reporting period. Do not report AFP endowments or matching funds. Identify which state level or leadership activity the funds were allocated to support. If funds were received to support more than one activity, report an amount for each activity according to funding allocations. The number of individuals served by those funds or other outcomes should have already been reported in the appropriate previous sections.

Fund Source	Amount	Use of Funds (select one)
		Ο State Financing Ο TrainingΟ Reutilization Ο Technical AssistanceΟ Demonstration Ο Public Awareness, I&A Ο Device Loan

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

Statewide AT Programs may also leverage funds to support activities not required by the AT Act or other activities not included in a State Plan. Examples of such activities might be conducting evaluations or assessments under contract with your state Vocational Rehabilitation Agency or developing a training curriculum for an agency on a non-AT topic. If an activity is approved as part of your state plan, it should NOT be reported here but should be reported in the appropriate previous section. This section is limited to only non-State Plan approved activities 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 individuals served is not an appropriate measure. Using the examples, you would report the number of individuals provided with evaluations or assessments or would describe the end product developed for training.

Fund Source	Amount	Use of Funds – select one	Individuals Served or Other Outcome
		Ο State FinancingΟ ReutilizationΟ DemonstrationΟ Device LoanΟ TrainingΟ Technical AssistanceΟ Public Awareness, I&A Ο Non-AT Act (describe the activity)	(enter the number of individuals served or describe the outcome)

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
Access Performance Measure

TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________  Services provided: Device demonstration OR Device loan  Date service delivery was completed: __________  Date this form was received: ____________________

Please answer the following questions about the services you received from the (insert name of statewide AT program or its subcontractor). We need this information to provide high quality services and to meet the requirements for receiving federal funding.

(Please mark only one answer.)

Education—participating in any type of educational program

Community living—carrying out daily activities, participating in community activities, using community services, or living independently

Employment—finding or keeping a job; getting a better job; or participating in an employment training program, vocational rehabilitation program, or other program related to employment

Information technology/telecommunications—using computers, software, Web sites, telephones, office equipment, and media

2. What kind of decision about AT devices or services were you (or someone you represent) able to make after your device demonstration or device loan?

(Please mark only one answer.)

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

_____ Decided that an AT device or service will not meet my needs (or the needs of someone I represent).

_____ Have not made a decision.

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. Jeremy Buzzell, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.

Data Collection Instrument
Acquisition Performance Measure

TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________  Services provided: “State financing” services—including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and services at reduced cost or free, or other related services Device exchange—received an AT device through a device exchange program Device recycling—received an AT device through a device recycling program OR Open-ended loan – received an AT device through an open-ended loan  Date service delivery was completed: __________  Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of statewide AT program or its subcontractor). We need this information to provide high-quality services and to meet the requirements for receiving federal funding.

1. The primary purpose for which I need (or the person I represent needs) an AT device or service is related to:

(Please mark only one answer.)

Education—participating in any type of educational program

Community living—carrying out daily activities, participating in community activities, using community services, or living independently

Employment—finding or keeping a job; getting a better job; participating in an employment training program, vocational rehabilitation program, or other program related to employment

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

(Please mark only one answer.)

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

_____ The AT was only available to me through this program. (I am not eligible or don't qualify for other programs, the AT is not covered by other funding sources or the specific device I needed is not provided by other programs.)

_____ The AT was available to me through other programs, but the system was too complex or the wait time was too long. 

_____ None of the above

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. Jeremy Buzzell, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.

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 reutilization— received an AT device through a device exchange or recycling 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. Jeremy Buzzell, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.