SGAT Customer 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

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 2.5 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 [email protected] and reference the OMB Control Number 1820-0572.