Statewide AT Customer Satisfaction Survey

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 2.5 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.