State Assessment and Performance Measurement Form

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.

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

(Please mark only one answer.)

Education—participating in any type of educational program

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

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

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.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required under the Assistive Technology Act of 1998, as amended, to retain benefit of the State Grant for AT Program. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0572.

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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required under the Assistive Technology Act of 1998, as amended, to retain benefit of the State Grant for AT Program. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0572.