At Apr

Annual Performance Report for the State Grant for Assistive Technology Program

0042 AT APR Instrument Final 508

OMB: 0985-0042

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Administration for Community Living
State Grants for Assistive Technology Program
Annual Progress Report (AT APR)
Data Collection Instrument

OMB # 0985-0042
Expiration Date:

Paperwork Reduction Act Public Burden Statement:
According to the Paperwork Reduction Act of 1995 5 CFR § 1320.8(b)(3), no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number (OMB 0985-0042). Public
reporting burden for this collection of information is estimated to average 404 hours per response, including time for
gathering, maintaining the data needed, completing, and reviewing the collection of information. The obligation to
respond to this collection is required to maintain or retain benefits under the 21st Century Assistive Technology Act
(AT Act of 1998, as Amended), applicable to Section 4 formula funded grantees for the State Grant for Assistive
Technology Program. This Information Collection (IC) contains data needed for completion of the State Grants for
AT Program Annual Progress Report (AT APR). The AT APR IC is designed to provide the Administration for
Community Living (ACL) with information necessary for program planning and reporting data on required statelevel and state leadership activities to Congress, the Secretary of Health and Human Services and additional entities.
The AT APR is organized by the state-level and state leadership activities outlined in the 21 st Century Assistive
Technology Act (AT Act of 1998, as Amended). State Lead agencies or Implementing Entities will report on these
state-level and state leadership activities and will provide data required by Section 4(f) of the Act and other
necessary information. Annual data and information from individual states will be available to the public once the
information is complete, formally submitted, reviewed, and published. Data will be kept private to the extent
allowed by law, there are no assurances of confidentiality. The states will not report information that identifies
individual consumers. States will provide anecdotes about the effect of their programs on individual consumers, but
states are instructed to write anecdotes in a manner that ensures their anonymity. All other data provided is reported
in the aggregate. The web-based system used for this instrument will not allow public access to the reporting
instrument for data entry, and states will have access to their data only. They will not be able to see or manipulate
data of other states. Individual state reports will be kept confidential until they have been finalized by the state and
accepted by ACL. Once a report has been finalized by the state and accepted by ACL, access to the aggregated statespecific and national data will be available to the public via the Internet. However, while the public will be able to
view the data, they will not be able to alter the data. States will be advised that their data will be available to the
public in this manner. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to Robert Groenendaal, Administration for Community
Living, 330 C Street, SW, Washington, DC 20201 or via E-Mail [email protected].

Page 1

Table of Contents

General Information ........................................................................................................................ 3
State Financing................................................................................................................................ 4
Reuse ............................................................................................................................................. 15
Device Loans ................................................................................................................................ 19
Device Demonstrations ................................................................................................................. 24
National Outcome Measures ......................................................................................................... 28
Educational/Training Activities ................................................................................................... 30
Technical Assistance ..................................................................................................................... 34
Public Awareness and Information and Assistance ...................................................................... 37
Coordination/Collaboration and State Improvement Outcomes ................................................... 40
Additional and Leveraged Funds .................................................................................................. 42
Data Collection Instrument Access Performance Measure .......................................................... 44
Data Collection Instrument Acquisition Performance Measure ................................................... 45
Data Collection Instrument ICT Accessibility Performance Measure ......................................... 47
Survey Instrument Customer Satisfaction .................................................................................... 48

Additional instructions for completion of this form and relevant definitions are
contained in a separate document, “Instruction Manual and Definitions for
the Annual Progress Report (APR) for State Grants for Assistive
Technology.”

Page 2

General Information
Statewide AT Program (Information to be listed in national State AT Program Directory)
1. State Program Title
2. State AT Program URL (home page for State AT Program)
3. Mailing address
5. State
4. City
6. Zip code
7. Main email address (for general public to use to contact State AT Program)
8. Main phone number (for general public to use to contact State AT Program)
9. Separate TTY number (for general public to use to contact State AT Program if applicable)
Lead Agency
10. Agency name
11. Mailing address
13. State
12. City
14. Zip code
15. Lead Agency URL
Implementing Entity
16. Does your Lead Agency contract with an Implementing Entity to carry out the Statewide AT Program
on its behalf? Yes
No
If yes, complete Items 17–22.
17. Name of implementing entity
18. Mailing address
20. State
19. City
21. Zip code
22. Implementing Entity URL
Program director and other contacts
23. Program Director for State AT Program (last, first)
24. Title
25. Phone
26. E-mail
27. Primary Contact at the Lead Agency (last, first)
28. Title
29. Phone
30. E-mail
31. Primary Contact at Implementing Entity (last, first) – If applicable
32. Title
33. Phone
34. E-mail
Person Responsible for completing this form if other than State AT Program Director
34. Name (last, first)
35. Title
36. Phone
37. E-mail
Certifying Representative
38. Name (last, first)
39. Title
40. Phone
41. E-mail

Page 3

State Financing

State Financing
Outline
Overview of Activities Performed
A. Financial loan programs
1. Loan applications
2. Income of applicants to whom loans were made
3. Loan type
4. Interest rates
5. Types and dollar amounts of AT financed
6. Defaults
7. Additional Data for Title III Funded AFP
B. State financing activities that provide consumers with resources and services that result in the
acquisition of AT devices and services
1. Overview of Activities Performed
2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and Services and
Number for whom Performance Measure Data are Collected
3. Types and dollar amounts of AT funded
C. State financing activities that allow consumers to obtain AT for a reduced cost
1. Overview of Activities Performed
2. Geographic Distribution and Number of Individuals Served
3. Savings to consumers, by type of AT device/service
D. Anecdote
E. Performance measures
F. Customer Satisfaction
G. Notes
Section 4f requirements: (1) the type of State financing activities…used by the State; (2) the amount
and type of assistance, including the number of applications for assistance received, the number of
applications approved and rejected, the default rate for the financing activities, range and average
interest rate for the financing activities, range and average income of approved applicants for the
financing activities, and the types and dollar amounts of AT financed; (3) consumers of the State
financing activities, who shall be classified by type of AT device or service and geographical distribution

A state financing activity is an activity approved as part of your State Plan for AT that
provides for the purchase, lease, or other acquisition of, or payment for AT including Statefinanced or privately financed alternative financing systems of subsidies. Examples of state
financing activities include, but are not limited to administering financial loan programs,
administering “last resort” activities funded with non-AT Act dollars, administering cooperative
buying programs, administering telecommunications distribution programs, and other activities
that result in the acquisition of AT devices and services. Programs that directly provide AT may
be programs operated with funds that are earmarked for particular types of consumers (such as
children), particular types of AT (such as home modification), or for individuals who meet
certain income limitations. States may not use AT Act dollars to provide funds or devices
directly to individuals. AT Act dollars may be used to administer a last resort fund comprised of
non-AT Act dollars.
Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting any State Financing
activities?
Check yes or leave unchecked. If yes, complete one or more of sections A, B, or C.

Page 4

State Financing
A. Financial Loan Programs

Did your approved State Plan include conducting a financial loan program?
leave unchecked.
1.

Check yes or

Loan Applications

In this section, report on both revolving loans and partnership loans. Revolving loans are
made directly by the financial loan program with funds from the loan fund account that are
repaid directly back into that account. The entire loan is serviced by the financial loan program.
Partnership loans use dollars from another source, usually a financial institution, in which the
financial loan program has an investment through loan guarantee, agreement with the partner
institution based on an investment deposit, interest or principal buy-down, or other financial or
administrative role.
In the table below, report information on loan applications made by Rural Urban Continuum
Code (RUCC) of the applicant’s county of residence and the decisions made about those
applications. Include all applications that were processed to one of the three decisions shown in
the table below (i.e., approved—loan not made, approved—loan made, or rejected) during this
reporting period, even if the application was received prior to the start of the reporting period.
Do not include applications not reviewed because they were not complete, were withdrawn
before a final decision was made, or were still pending at the end of the reporting period. For
guidance on how to classify the applicant’s area of residence as metro or non-metro, please see
the Instruction Manual.

Number of Applications
A. Approved—loan made

Area of Residence
Metro
Non-Metro
RUCC 1-3
RUCC 4-9

Systemgenerated
Systemgenerated

B. Approved—loan not made (i.e., the application was
withdrawn after the loan was approved, or the loan
was approved but not accepted by the consumer)
C. Rejected
D. Total

Total

Systemgenerated

Systemgenerated
Systemgenerated

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 above). For purposes of this section, the income
of these applicants is the gross annual income that the applicants reported on the loan
applications (i.e., the amount upon which the decision about the loan was based.) This may be
the income of the individual, the family, and/or one or more co-borrowers.
a. Enter the lowest and highest income reported among all applicants to whom loans were
made during the reporting period:
Lowest: $______________
Highest: $______________

Page 5

State Financing

b. Use the table below to calculate the average gross annual income of applicants to whom
loans were made. In Column A, enter the sum of the incomes reported by all applicants
to whom loans were made. The system will divide that amount by the number of
applicants to whom loans were made (as reported in row A of the table above to calculate
the average income.
A
Sum of Incomes
$

B
Number of Applicants to Whom Loans
Were Made
System-generated

C
Average Gross
Annual Income
System-generated

c. In the table below, enter the number of loans made to applicants who reported incomes in
each of the specified ranges. The total number of loans should match the number you
reported in row A of the first table. The system will calculate the percentage of loans
made to individuals in each income category.

$15,000 or
Less

Number and Percentage of Loans
Made to Applicants with Incomes of
$15,001 to $30,001 to $45,001 to $60,001 to
$30,000
$45,000
$60,000
$75,000

$75,001 or
More

Total
Number of
Systemloans
generated
Percentage
SystemSystemSystemSystemSystemSystemSystemof loans
generated
generated
generated
generated
generated
generated 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 A.1.)

Loan Type

a) Enter the number of loans by loan type as defined below. The system will calculate the
percentage of loans that fall into each category. Report each loan in only one category.
Revolving loan fund (or revolving loan): A loan fund that uses Statewide AT Program funds
for loans. The AT program directly provides the funds that are to be loaned out and retains full
control over to whom and at what terms the funds are loaned. As loans are repaid, the money is
lent out again to other AT consumers — that is, the same money “revolves” out to other
borrowers as earlier borrowers return it to the program.
Partnership loan: A loan administered by and using dollars from a source other than the
Statewide AT Program, usually a financial entity, for which the Statewide AT Program has a
direct financial investment through interest or principal buy-down, loan guarantee, or agreement
with a financial institution based on an investment deposit or other written agreement with
documentation of the subsidy provided for loans made (e.g. the financial institution provides a
prime or less interest rate without buy-down payment.)
Interest buy-down loan: A partnership loan in which AT program funds are used to buy down
the interest rate of a loan. The AT program uses funds to reduce the interest rate that lending
institutions offer to consumers for loans to purchase AT. The AT program pays the lending
institution for a portion of the interest on the loan, resulting in lower interest payments for the
consumer over the long term.

Page 6

State Financing

Loan guarantee: A partnership loan in which the Statewide AT Program guarantees that the
loan to a consumer is secure and will be repaid, thus increasing the lender’s willingness to loan
funds.
Number
of Loans

Type of Loan

Percentage
of Loans
System-generated

Revolving Loans
Partnership Loans
Without interest buy-down or loan guarantee
Mandatory Explanation
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
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 A.1.)

If a number is reported under Partnership Loans without interest buy-down or loan guarantee you
must have a written agreement with the partner organization and must describe the subsidy
provided by these loans or other investment of the financial loan program in these loans.
Verification that these loans are all low interest (prime or less) will provide the required subsidy
documentation. If these loans are not low interest, other verification of the clear subsidy and
investment of the financial loan program in these specific loans must be described.
______________________________________________________________________________
b) Enter the dollar value of 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 only once.
Type of Loan

Number of Loans

Dollar Value of Loans

Revolving loans

System-generated

Partnership loans

System-generated

Total

System-generated

Interest Rates

a) Enter the lowest and highest interest rates among all loans made, including both revolving
and partnership loans. For interest buy-downs, report the interest rate to which you bought the
loan down:
Lowest: ______________%
Highest: ______________%
b) Use the table below to calculate the average interest rate for all loans, including both
revolving and partnership loans. Enter the sum of interest rates for all loans in Column A. The
system will divide that amount by the number of loans made as previously reported and
automatically populated in row A to calculate the average interest rate.
A
Sum of Interest Rates

B
Number of Loans Made
System-generated

C
Average Interest Rate
System-generated

c) In the table below, enter the number of loans made at interest rates in each of the specified
ranges. The total number of loans should match the number you reported in row A of the table in
Section A.1. above.
Page 7

State Financing

Number of Loans Made at Interest Rates of -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+%

Total Number
of Loans

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/service in
only one category. For guidance on how to classify devices and services, and decision rules for
devices and services, refer to the Instruction Manual. Because a single loan may pay for more
than one device or service, the number of devices and services reported in this table may exceed
the number of loans. However, the total dollar value of loans should be the same as reported
previously in 3.b.
For large building access projects or similar activities with multiple devices in one AT
category, the numbers reported should reflect a logical access grouping (e.g., a bathroom
modification or exterior ramping of a house would be a home modification). Where an AT
service (such as an evaluation) was part of a financial loan, include that dollar amount in the
appropriate AT category associated with the service (e.g., an audiological evaluation would go in
the “hearing” category).
If the loan is a refinance, and the AT purchased with previous loan has never been reported,
you should report the AT devices/services purchased with the previous loan as the AT associated
with the refinance. (NOTE: If the refinance is of a previous loan and the AT purchased with the
previous loan has been reported, the refinance should not be reported at all.)
Type of AT Device/Service
Number of Devices Financed
Dollar Value of Loans
Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Total
System-generated
$ System-generated
(System will generate an error message if total dollar value of loans does not match amount reported in
the Total Dollar Value of Revolving Loans and Partnership Loans calculated in Item 3(b) above.)

6. Defaults

In the first cell below, enter the number of loans that were in default during this reporting
period. A loan is in default after 120 days in which the borrower has not made the scheduled
payment for the balance still owed; or at which time the organization administering the loan paid
the lending institution the remaining agreed upon balance of loan. Do not count any payments
that may have been made by the loan administering organization on behalf of the borrower
Page 8

State Financing

during that 120-day period as payments made by the borrower. (Rescue payments do not count
as borrower payments and the 120-day clock continues.)
In the second cell below, enter the net dollar loss on defaulted loans. Net dollar loss on
loans means the amount lost as a result of default during this reporting period after subtracting
any funds that were recovered. It includes the amount that is unpaid on any loans in default and
any loan guarantee payout amounts minus the amount of collateral recovered.
Number of Loans in Default

Net Dollar Loss on Loans

Note: If you have a loan in default for this reporting period and you reasonably believe you will
be able to recoup some of the net dollar loss associated with this default during the next reporting
period you can choose to defer reporting the default and the net dollar loss until the next
reporting period. This should only occur when loans went into default later in the current
reporting period and you have not had sufficient time to sell or otherwise recoup some of the
value of the collateral.
B. State Financing Activities that Provide Consumers with resources and services that
result in the acquisition of AT devices and services
1.

Overview of Activities Performed

How many other state financing activities that provide consumers with access to funds for the
purchase of AT devices and services were included in your approved State Plan? – enter
number. Which of the following best describes this state financing activity? Drop-down box: (1)
last resort activity; (2) telecommunications equipment distribution program (including
deaf/blind EDP); (3) lease-to-own program, (4) other (specify)
2. Geographic Distribution, Number of Individuals Who Acquired AT Devices and
Services and Number for whom Performance Measure Data are Collected

In this table, report the number of individuals who acquired AT devices and services through
this activity, by the Rural Urban Continuum Code (RUCC) for the county in which they reside.
For guidance on how to find a county’s RUCC, please see the Instruction Manual.
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.
County of Residence
A.Metro (RUCC 1-3)
B.Non-Metro (RUCC 4-9)
C. Total Served
D. Excluded from Performance Measure (Number of individuals excluded from
performance measure data collection because AT is provided to or on behalf of an entity that has
an obligation to provide the AT such as schools under IDEA or VR agencies/clients)

Individuals Served

i System-generated
Mandatory
explanation

Page 9

State Financing
E. Number of Individuals Included in Performance Measures

ii System-generated
(ii = i minus excluded number D)

If a number is reported in D you must provide a description of the reason the individuals are
excluded from the performance measure: _________________________________________
3.

Types and Dollar Amounts of AT Funded

Use the table below to provide information on the number of devices or services funded and
the amount of funding provided, by type of AT device/service. Report each device or service in
only one category. Because a single recipient may acquire more than one device or service, the
number of devices and services reported in this table may exceed the number of recipients. Refer
to the Instruction Manual for decision rules on how to classify devices and services.
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
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
Total

Number of Devices
Funded

System-generated

Value of AT Provided
$
$
$
$
$
$
$
$
$
$
$ System-generated

C. State Financing Activities that Allow Consumers to Obtain AT for a Reduced Cost
1.

Overview of Activities Performed

How many activities that allow consumers to obtain AT for a reduced cost were included in your
approved State Plan? – enter number. Which of the following best describes this state financing
activity? Drop-down box: (1) cooperative buying program; (2) AT leasing for savings program;
(3) AT fabrication or AT maker program; (4) other (specify)
2.

Geographic Distribution and Number of Individuals Served

State Financing

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 Must Provide Performance Measure Data” for more information.
Number of
Individuals Served

County of Residence
A.Metro (RUCC 1-3)
B.Non-Metro (RUCC 4-9)
C. Total Served

i System-generated

D. Excluded from Performance Measure (Number of individuals excluded from

Mandatory
explanation
ii System-generated
(ii = i minus excluded number D.)

performance measure data collection because AT is provided to or on behalf of an entity that has
an obligation to provide the AT such as schools under IDEA or VR agencies/clients)

E. Number of Individuals Included in Performance Measures

If a number is reported in D you must provide a description of the reason the individuals are
excluded from the performance measure: _________________________________________
3.

Savings to Consumers, by Type of AT Device/Service

Use the table below to provide information on the number of devices or services provided to
consumers and the savings to consumers resulting from this activity, by type of AT device or
service. Report each device or service in only one category. Because a single recipient may
acquire more than one device or service, the number of devices and services reported in this table
may exceed the number of recipients. Refer to the Instruction Manual for decision rules on how
to classify devices and services.
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. In the case of fabrication or AT maker programs you will use the retail price of a
comparable product to that which is being fabricated/made. In some cases, you may need to
identify multiple similar devices and average to estimate a MSRP. If the device was given away,
use a sale price of zero in your calculations.
For large building access projects, the numbers reported should reflect a logical access
grouping (e.g., a bathroom modification or exterior ramping of a house would each be one home
modification). Where funding was provided for an AT service (such as an evaluation), include
that dollar amount in the appropriate AT category associated with the service (e.g., an
audiological evaluation would go in the “hearing” category).

Page 11

State Financing

Type of AT Device/Service
Vision
Hearing
Speech communication
Learning, cognition, and
developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and
transportation
Computers and related
Recreation, sports, and leisure
Total

Number
Provided

Total Estimated
Current Retail
Purchase Price

Total Price for
Which Devices
Were Sold

Savings
to Consumers
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated

Systemgenerated

System-generated

System-generated System-generated

D. Anecdote

Provide at least ONE anecdote about an individual who benefited from a state financing
activity. Do not provide more than TWO anecdotes. If you have a picture to accompany the
narrative you submit, please check the box provided. Each narrative is limited to 1800
characters. Please check the area (education, employment, or community living) of the
outcome/impact of the anecdote.
(Narrative item #1)
Impact area:

 Education

 Employment

 Community Living

If you have a picture to accompany anecdote #1, please add here with alt text.
(Narrative item #2)
Impact area:

 Education

 Employment

 Community Living

If you have a picture to accompany anecdote #2, please add it here with alt text.
E.

Performance Measures

State financing activities are covered by the Acquisition Performance Measure. To collect
data for this measure, statewide AT programs will collect follow-up information from
consumers. Use data collected from consumers to complete the table below. Refer to the
Instruction Manual for guidance on how to categorize the primary purpose for which AT
devices/service are needed.

Page 12

State Financing

The total number of customers from whom data is reported must equal the sum of the
number of individuals to whom financial loans were made (as reported in Section A.1.A) and the
number of individual recipients of other state financing activities who are included in
performance measures (as reported in Sections B.2.E.ii and C.2.E.ii).
Response

Primary Purpose for Which AT is Needed
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

Total

Systemgenerated

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.
Non-respondents are included in denominator. (System will generate an error message if total reported in
column at far right does not equal total of Sections A.1.A plus B.2.E.ii plus C.2.E.ii )

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
Highly satisfied
Satisfied
Satisfied somewhat
Not at all satisfied
Nonrespondent
Total
Response rate

Number of Customers

Percent
System-generated
System-generated
System-generated
System-generated
System-generated

System-generated
System-generated

(System will generate an error message if total does not equal total reported in Sections A.1.A
plus B.2.C.i plus C.2.C.i.)
G. Notes

Describe any unique issues that may affect your data in this section (e.g., types of
devices/services that may not be financed because they are financed by other programs).
(Narrative item)
Page 13

State Financing

Page 14

Reuse
Outline
Overview of Activities Performed
A. Number of recipients of reused devices
B. Device exchange activities
C. Device Reassignment/Refurbishment and Repair Activities
D. Open-ended loans
E. Anecdote
F. Performance measures
G. Customer satisfaction
H. Notes
Section 4f requirement: the number, type, estimated value, and scope of assistive technology devices
exchanged, repaired, recycled, or reutilized (including redistributed through device sales, loans,
rentals, or donations) through the device reutilization activities, and an analysis of the individuals with
disabilities that have benefited from the device reutilization activities

Device reuse includes device exchange activities and device refurbishment/repair activities in
which the device can be reassigned or placed on open-ended loan where the borrower can keep
the device for as long as it is needed. All of these types of reuse are considered a form of
“acquisition.”
Device exchange activities are those in which devices are listed in a “want ad”-type posting
and consumers can contact and arrange to obtain the device (either by purchasing it or obtaining
it for free) from the current owner. Exchange activities do not involve warehousing inventory
and do not include sanitation or refurbishing of used devices.
To report all required device exchange data, a Statewide AT Program will need to be able to
collect performance measure outcome data. If the device buyer and seller make the exchange
transaction without any involvement of the Statewide AT Program it will challenging to
accurately gather and report required performance measure data at the conclusion of the
exchange. While an online exchange listing system may be able to automatically collect some
data from the seller and/or device listing (category of AT), the State AT Program must be able to
confirm the exchange transaction was completed, verify the final sale price of the device, and
attempt to collect performance measure data directly from the buyer after the exchange
transaction is complete. This will require direct interaction with the end recipient to verify the
completed exchange data and request a response to the performance measure. If your exchange
program does not provide a mechanism to directly interact with the end recipient of device
exchange and collect this required data, you should not report this activity data in the Annual
Progress Report.
Device sanitation/refurbishment/repair activities are those in which devices are accepted (usually
by donation) into an inventory; are sanitized and/or refurbished as needed; and then offered for
sale, open-ended loan, or give away to consumers as redistributed products. Repair activities are
those in which device(s) are repaired for an individual (without the ownership of the device
changing hands) which prevent the owner from needing to purchase a new device.

Page 14

Reuse

Devices in a reuse inventory can be reassigned on a permanent basis to a new “owner” or
provided as an open-ended loan to a borrower as long as required to meet a particular need.
Open-ended device loans are generally distinguishable from short-term device loans by the
length of the typical loan period and/or lack of a set short-term period that is known to be
appropriate for the loan. Open-ended loans are generally longer term without a known
appropriate end-date and/or the device placed with a consumer on an ongoing basis but without
transferring ownership to the consumer.
Devices produced as a result of AT “maker” or fabrication activities MAY be included in
reutilization if the fabricated devices are provided as open-ended loans, with the expectation that
the devices will be returned to the program’s inventory when no longer needed. In general,
however, AT fabrication should be considered as an “other” type of state financing as devices
fabricated are frequently made specifically for an individual. In any case, devices produced
through maker or fabrication activities must be counted as only one acquisition unless the
fabricated device is taken back into the inventory of the reuse program from the original
recipient and provided to a new recipient.

Overview of Activities Performed
Did your approved State Plan for this reporting period include conducting any device reuse
activities? Check yes or leave unchecked.
A. Number of Recipients of Reused Devices

In this table, report the number of recipients who receive devices through device exchange or
refurbish/ repair (reassign and/or open-ended loans). Recipients should be reported only once,
even if they receive multiple devices as part of a reuse event. Of the recipients reported, identify
the number for whom performance measure data cannot be reported. Some entities that have an
obligation to provide AT may provide it via reuse. For example, a school has an obligation to
provide AT devices identified in an IEP and the school may obtain the device through the reuse
program. In this case, the performance measure questions are not answerable by the school
because the issues of affordability or availability are not allowable reasons to limit access to AT
that has been identified as necessary by the IEP team. You should exclude from the performance
measures device recipients who acquire reused devices under these circumstances.
Activity
A. Device exchange
B. Device Refurbish/Repair – Reassign and/or Open-Ended Loan
C. Total Served
D. – Excluded from Performance Measure because AT is provided to or on
behalf of an entity that has an obligation to provide the AT such as schools
under IDEA or VR agencies/clients)

E. Number of Individuals Included in Performance Measures

Number of Individuals
Receiving a Device from Activity

i System-generated
Mandatory explanation
ii System-generated
(ii = i minus excluded number D)

If a number is reported in D. you must provide a description of the reason the individuals are
excluded from the performance measure: _________________________________________

Page 16

Reuse
B. Device Exchange Activities

Enter the total number of devices exchanged (listed by one individual/entity and obtained by
another) during the reporting period, by AT type. Because a single recipient may acquire more
than one device or service, the number of devices and services reported in this table may exceed
the number of recipients. For each type of AT device, enter the total estimated current purchase
price of the devices and the total amount for which the devices were exchanged. To report a
device as “exchanged” you must have documentation of the price for which it was sold or
exchanged. Use the Manufacturer’s Suggested Retail Price (MSRP) to determine the current
purchase price of the device. If you are unable to find the exact price for a particular item, use
the value of a comparable device. You may need to identify multiple similar products and
average to identify a MSRP. Using estimates is acceptable when exact pricing information is not
available. If the device was given away, use a sale price of zero in your calculations. The system
will calculate the resulting savings to consumers in the last column.
Type of AT Device

Number of
Devices
Exchanged

Total Estimated
Current Purchase
Price

Total Price for
Which Device(s)
Were Exchanged

Savings to
Consumers

Vision

System-generated

Hearing

System-generated

Speech communication

System-generated

Learning, cognition & developmental

System-generated

Mobility, seating and positioning

System-generated

Daily living

System-generated

Environmental adaptations

System-generated

Vehicle modification & transportation

System-generated

Computers and related

System-generated

Recreation, sports and leisure

System-generated

Total

Systemgenerated

System-generated

System-generated System-generated

C. Device Refurbish/Repair - Reassignment and/or Open-ended Loan Activities

Enter the total number of devices sanitized/refurbished/repaired and acquired by an end user
through reassignment or open-ended loan during the reporting period, by type. Because a single
recipient may acquire more than one device or service, the number of devices and services
reported in this table may exceed the number of recipients. However, multiple devices within the
same AT category grouped together for a function should be reported as one device (e.g.
multiple components of a functional seating system). For each type of AT device acquired, enter
the total estimated current purchase price of the device and total price for which the devices were
sold. The system will calculate the savings to consumers. Use the MSRP for the current
purchase price of the device. If you are unable to find the exact price for an item, use the value
of a comparable device. You may need to identify multiple similar products and average for an
MSRP. 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.
NOTE: Open-ended loans are reported only once in the reporting period the loan is made; not in
subsequent years even if the loan is still open.

Page 17

Reuse

Number of Devices
Sanitized/Repaired
/Refurbished

Type of AT Device

Total Estimated
Current 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 & positioning

System-generated

Daily living

System-generated

Environmental adaptations

System-generated

Vehicle modification & transportation

System-generated

Computers and related

System-generated

Recreation, sports and leisure

System-generated

Total

System-generated

D. Anecdote

Provide ONE anecdote about an individual who benefited from a reuse activity. For
guidance on information to include in the anecdote, please see the Instruction Manual. If you
have a picture to accompany the narrative you submit, please check the box provided. Each
narrative is limited to 1800 characters. Please check the area (education, employment, or
community living) of the outcome/impact of the anecdote.
(Narrative item)
Impact area:

 Education

 Employment

 Community Living

If you have a picture to accompany the anecdote, please add it here.

E. Performance Measures

Device reuse activities are covered by the Acquisition Performance Measure. To report data
for this measure, statewide AT programs will collect follow-up information from consumers to
complete the tables below. Refer to the Instruction Manual for guidance on how to categorize
the primary purpose for which AT devices/services are needed.
Performance measure for exchange, reassignment/refurbishment and repair and open-ended
device loan activities should be reported in the table below. The number of customers reported
should equal the total number reported in (ii) of Section A.
Primary Purpose for Which AT is Needed
Response
1. Could only afford the AT through the
statewide AT program (n,d)

Education

Employment

Community Living

Total

Page 18

Reuse
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 wait time was too long (n,d)
4. Subtotal
5. None of the above (d)
6. Subtotal
7. Nonrespondent (d)
8. Total

System-generated

System-generated System-generated

System-generated

System-generated System-generated

System-generated

System-generated System-generated

9. Performance on this measure

System-generated

System-generated System-generated

Systemgenerated

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

F. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the
table below for all customers served by device reuse activities. For exchange activities, you may
collect and report satisfaction data from either the device seller or the device recipient in a
completed exchange, but not both.
Customer Rating of Services

Number of Customers

Percent

Highly satisfied

System-generated

Satisfied

System-generated

Satisfied somewhat

System-generated

Not at all satisfied

System-generated

Nonrespondent

System-generated

Total surveyed

System-generated

Response rate
System-generated
(System will generate an error message if total surveyed is not equal to the number of individuals who
acquired a reused device reported in Section A(i).

G. Notes

Describe any unique issues that may affect your data in this section. If you have a device
exchange program, please describe your data collection method, any challenges with collecting
these data, and plans for overcoming those challenges.
(Narrative item)

Page 19

Device Loans
Outline
Overview of Activities Performed
A. Short-Term Device Loans by Type of Purpose
B. Number of Device Loans by Type of Borrower
C. Length of short-term device loans
D. Types of devices loaned
E. Anecdote
F. Performance measures
G. Customer satisfaction
H. Notes
Section 4f requirement: the number, type, and length of time of loans of assistive technology devices
provided to individuals with disabilities, employers, public agencies, or public accommodations through
the device loan program…and an analysis of individuals with disabilities who have benefited from the
device loan program

Statewide AT programs provide short-term loans of AT devices to individuals or entities.
The loan purpose may be to assist in decision making, to serve as a loaner while the consumer is
waiting for device repair or funding, to provide an accommodation on a short-term basis for a
time-limited event, for educational/training, or other professional development activities. Loans
for the purpose of decision-making should be included in the access performance measure. Loans
for all other purposes: providing a device during repair, while waiting for funding, providing an
accommodation for a time-limited event, and educational/training or personnel development
should be included in the acquisition performance measure.
In this section, report only on short-term loans in which devices are borrowed for a limited
or prescribed amount of time for one of the four purposes described in Section A. Based on
national data, typical short-term loan periods range from between 30 and 45 calendar days.
Device loans for significantly longer periods should be reviewed as possible open-ended loans,
especially when the loan structure is done as an alternative to device ownership transferring to
the consumer. Open-ended device loans, in which the device borrower can keep the device for as
long as it is needed, should be reported under “Device Reuse.”
Overview of Activities Performed

Did your approved State Plan for this reporting period include conducting short-term device
loans? check yes or leave unchecked.
A. Short-Term Device Loans by Type of Purpose

In this section, report the total number of short-term device loans made during the reporting
period. A loan (counted as one) is defined as an occasion on which a device or devices were
borrowed by an individual/entity who will use the device for one of the following purposes -1) To make a decision (one decision even if multiple devices in the same AT category were
borrowed) based on data, judgments, and other relevant information gained from trial use of
the device in a natural environment with technical assistance available, upon request, from
someone who has technical expertise related to the device(s) borrowed.

Page 19

Device Loans

2) To provide loaner equipment during device repair or while waiting for funding (no decision
is involved).
3) To provide an accommodation for a time-limited event such as a meeting or situation such
as a hospital stay (no decision is involved). Device loans that provide an accommodation for
a longer period of time should be carefully reviewed to ensure it is indeed a short-term loan
and not more of an open-ended loan (reported in reuse) in which the borrower needs to use the
device for a longer period of time.
4) To conduct educational/training activities, self-education, or other professional
development activities (no decision involved).
The number of short-term device loans will equal the number of borrowers reported in B, as each
loan will be classified by the type of individual or entity that borrows. The number of loans will
NOT necessarily equal the number of devices borrowed as reported in D as there may be
multiple devices borrowed within a single loan event. A device loan event for decision-making
is defined by the decision to be made. In general, the decision will be based on borrowing one or
more devices within a single AT category in which the device loan event is reported. The same
individual may borrow multiple vision devices at the same time or across time (borrow one
device, return it, borrow another, return it) to make one overall decision which is one loan event
with multiple devices and one decision outcome. Or the same individual can borrow multiple
vision devices (same or across time) and the purpose is separate decisions (e.g. a provider is
borrowing to make decisions on behalf of different beneficiaries which is multiple loan events.)
It is critical to identify the purpose of the device loan first so that the loan event data can be
structured to collect accurate data for that event. If a loan is extended it should not be counted as
a separate loan unless the extension creates a new, separate loan event purpose.
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 borrowed for decision-making, report the loan in the first row.
Primary Purpose of Short-Term Device Loan

Number of Loans

1. Assist in decision making (device trial or evaluation)

Access Performance Measure

2. Serve as loaner during device repair or while waiting for funding

Acquisition Performance Measure

3. Provide an accommodation on a short-term basis for a time-limited
event/situation

Acquisition Performance Measure

4. Conduct education/training or other professional development activity

Acquisition Performance Measure

Total

i. System-generated

B. Number of Device Loans by Type of Borrower

In this section, report the number of device loans by type of borrowers - type of individual
or entity by decision-making purpose and by all other purposes. For guidance on how to
categorize borrowers, refer to the Instruction Manual. You must be able to categorize borrowers
to report them in this table as there is no option for “unable to categorize” or “other”.
The total number of device borrowers for decision-making purpose (total line i below) must
equal Section A line 1 above. The total number of device borrowers for all other purposes (total

Page 21

Device Loans

line ii below) must equal the sum of Section A lines 2, 3 and 4 above. The total number of
device borrowers (total line iii below) must equal the total number of short-term device loans
reported above in Section A.
Number of Borrowers
Type of Individual or Entity

Decisionmaking

Individuals with disabilities
Family members, guardians, and authorized representatives
Representatives of Education
Representatives of Employment
Representatives of Health, allied health, and rehabilitation
Representatives of Community Living
Representatives of Technology
Total

All other
Purposes

Total
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated

i. Systemgenerated

ii. Systemgenerated

iii. Systemgenerated

C. Length of Short-Term Device Loans

Enter the standard length of loan established by your AT Program policies/procedures not
including extensions. Please report the length in calendar days. If your policy/procedures
establish a range, use the midpoint. Please note this is NOT actual days, it is your policy period.
Length of short-term device loan, in days: (Numeric field)
D. Types of Devices Loaned

Enter the number of devices that were loaned by device type for decision-making and for all
other purposes. For guidance on how to categorize devices, refer to the Instruction Manual. The
number of devices loaned may exceed the number of loans reported in Section A since one loan
may include more than one device. The total of i. must be greater than or equal to Section A line
1 and ii must be greater than or equal to the sum of lines 2, 3 and 4 in Section A.
Type of AT Device

Number of Devices
Decision-making

All other Purposes

Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Total

Total
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated

i. Systemgenerated

ii. Systemgenerated

iii. System-generated

Page 22

Device Loans
E.

Anecdote

Provide ONE anecdote about an individual who benefited from a device loan activity. For
guidance on information to include in the anecdote, please see the Instruction Manual. If you
have a picture to accompany the narrative you submit, please check the box provided. Each
narrative is limited to 1800 characters. Please check the area (education, employment, or
community living) of the outcome/impact of the anecdote.
(Narrative item)
Impact area:

 Education

 Employment

 Community Living

If you have a picture to accompany the anecdote, please add it here.

Access Performance Measures

Device loan activities for a decision-making purpose are covered by the Access Performance
Measure. To collect data for this measure, statewide AT programs will collect access
performance measure data from all borrowers who obtained device loans for the purpose of
decision-making (the number reported in Section B i.). That data will be used to complete the
table below. Refer to the Instruction Manual for guidance on how to categorize the primary
purpose for which AT devices/services are needed.
Primary Purpose for Which AT is Needed

Response
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
4. Have not made a
decision (d)
5. Subtotal
6. Nonrespondent
(d, if > 35%)
7. Total

Education

Employment

Total

Community Living

System-generated System-generated

System-generated

System-generated System-generated

System-generated

System-generated System-generated

System-generated

Systemgenerated

System-generated
8. Performance on this System-generated System-generated
measure
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 Section B.i.)

G. Acquisition Performance Measures

Device loan activities for the purpose of providing loaner equipment during device repair or
while waiting for funding, for providing an accommodation for a time-limited event, and for
Page 23

Device Loans

professional development activities are covered by the Acquisition Performance Measure. To
report data for this measure, statewide AT programs will collect follow-up information from
borrowers to complete the table below. Refer to the Instruction Manual for guidance on how to
categorize the primary purpose for which AT devices/services are needed. The number of
borrowers reported must equal the total number reported in Section B ii.
Primary Purpose for Which AT is Needed
Response

Education

Employment

1. Could only afford to borrow the AT
through the statewide AT program
(n,d)
2. AT was only available through the
statewide AT program (n,d)
3. AT was available to borrow from
other programs, but the system was
too complex or the wait time was too
long (n,d)
System-generated System-generated
4. Subtotal
5. None of the above (d)
System-generated System-generated
6. Subtotal
7. Nonrespondent (d if > 35%)
System-generated System-generated
8. Total

Community Living

Total

System-generated

Systemgenerated

System-generated System-generated
System-generated
9. Performance on this measure
NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator.
Nonrespondents are included in the denominator for calculation of performance. (System will generate an
error message if total reported in column at far right does not equal total of Section B ii.)

H. . Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the
table below for all borrowers served by device loans (total in A.i.)
Customer Rating of Services
Highly satisfied
Satisfied
Satisfied somewhat
Not at all satisfied
Nonrespondent
Total
Response rate

Number of Customers

Percent
System-generated
System-generated
System-generated
System-generated
System-generated

System-generated
System-generated

I . Notes

Describe any unique issues that may affect your data in this section (e.g., types of devices
that are not loaned because those loans are available from another source, or types of devices that
are not loaned because your inventory does not include those devices, difficulty obtaining data
from intermediaries, etc.)
(Narrative item)

Page 24

Device Demonstrations
Outline
Overview of Activities Performed
A. Number of Device Demonstrations by Device Type
B. Types of participants
C. Number of referrals
D. Anecdote
E. Performance measures
F. Customer satisfaction
G. Notes
Section 4f requirement: the number and type of device demonstrations and referrals provided and an
analysis of individuals with disabilities who have benefited from the demonstrations and referrals

Device demonstrations compare the features and benefits of a particular AT device or
category of devices for an individual or small group of individuals. The purpose of a device
demonstration is to enable an individual to make an informed choice. Whenever possible, the
participant should be shown a variety of devices to compare features to support decision making.
Device demonstrations should not be confused with educational/training activities during
which devices are demonstrated. Educational/training activities are instructional events designed
to increase knowledge, skills, and competencies, generally for larger audiences or targeted
instruction for a small group focused on skill development whereas device demonstrations are
for decision-making purposes. Device demonstrations also should not be confused with public
awareness activities at which devices are demonstrated. The key difference is that device
demonstrations are intended to enable an individual to make an informed choice rather than
merely making him or her aware of a variety of AT.
In a device demonstration individual, guided experience with the device(s) is provided to the
participant decision-maker 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. A demonstration is characterized by
its interactive nature whereby the participant can interact with an expert to increase their
knowledge and understanding about the details and functions of a device; the participant drives
the demonstration and has the ability to interact and have their individual questions about the
device addressed. If the demonstration is conducted via the internet or distance learning
mechanism it must be a real-time, interactive demonstration that provides one-on-one assistance
to the participant. A web-based demonstration that is archived or is a static presentation without
interaction is considered an awareness activity, not a demonstration.
If a demonstration is to be conducted without the participant having direct (hands-on) access to
the devices to be demonstrated, the interaction must be structured to ensure the device can be
adequately explored to enable decision-making. For many types of AT devices, it will not be
possible to provide adequate interaction in a demonstration without the device being in the hands
of the participant. For example, a demonstration of a daily living aid like a “pill minder” might
be done with the participant asking the demonstrator to fill, set and use the device while they
watched on interactive video that might provide adequate information for decision-making.

Page 24

Device Demonstrations

However, having a demonstrator “show” a Braille note taker to an individual with a vision
disability via interactive video would not be adequate.
Following a device demonstration, provision of information about a specific source where the
customer may obtain additional information or services related to the devices demonstrated is
reported as a referral. 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 referral service.
Overview of Activities Performed

Did your approved State Plan for this reporting period include conduct device demonstrations?
Check yes or leave unchecked.
A. Number of Device Demonstrations by Device Type

In this section, report the number of device demonstrations by type of device/service
demonstrated during this reporting period. For guidance on how to categorize devices and
services, refer to the Instruction Manual. A device demonstration (counted as one) is defined as
an occasion in which one or more devices within one AT category are demonstrated to an
individual or small group one of whom will make a decision (one decision) based on data,
judgments, comparisons and other relevant information gained from the interaction with the
equipment and demonstrator. The number of device demonstrations will NOT necessarily equal
the number of demonstration participants reported in B as there may be multiple participants in a
demonstration even though only one decision will be made by the identified decision-maker
participant. Most often the decision-maker is the individual with a disability who is exploring
devices to meet their own needs. Other decision-makers include parents on behalf of their
children and providers on behalf of agencies who are acquiring a device on behalf of a client.

Type of AT Device/Service
Vision
Hearing
Speech communication
Learning, cognition, and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modification and transportation
Computers and related
Recreation, sports, and leisure
Total

Number of Demonstrations of
this Type of AT Device/Service

System-generated

Page 26

Device Demonstrations
B. Types of Participants

In the table below, enter the number of individuals who participated in a device
demonstration, by type. For guidance on how to categorize participants, refer to the Instruction
Manual. Report the type of individual who is making the decision for the demonstration (an
individual with a disability on their behalf or other individual or behalf of an individual with a
disability) separately from all other participants. The total number of decision-making
participants (i. below) must equal the total number of demonstrations above in Section A since
there is one decision-maker identified for each demonstration event who must provide the
performance measure outcome.
Decisionmaker

Type of Participant

Other
Participants

Total

Individuals with disabilities

System-generated

Family members, guardians, authorized representatives

System-generated

Representatives of Education

System-generated

Representatives of Employment

System-generated

Representatives of Health, allied health, rehabilitation

System-generated

Representatives of Community Living

System-generated

Representatives of Technology

System-generated
i. Systemgenerated

Total

Systemgenerated

System-generated

C. Number of Referrals

In this section, report the number of referrals made to each type of entity. Since participants in
a demonstration may receive more than one referral, or may not be referred at all, the number of
referrals may be greater or less than the number of participants and number of demonstrations.
Do not include referrals to other components of your Statewide AT Program
Type of Entity

Number of Referrals

Funding source (non-AT program)
Service provider
Vendor
Repair service
Others

D. Anecdote

Provide ONE anecdote about an individual who benefited from a device demonstration. For
guidance on information to include in the anecdote, see Instruction Manual. If you have a picture
to accompany the narrative, please check the box provided. Each narrative is limited to 1800
characters. Please check the area (education, employment, or community living) of the
outcome/impact of the anecdote.
(Narrative item)
Impact area:

 Education

 Employment

 Community Living

Page 27

Device Demonstrations

If you have a picture to accompany the anecdote, please add it here.
E. Performance Measures

Device demonstrations are covered by the access performance measure. To collect data for this
measure, statewide AT programs will collect data from the identified decision-maker who
participated in demonstrations (one per demonstration as reported in Item A). That data will be
used to complete the table below. Refer to the Instruction Manual for guidance on how to
categorize the primary purpose for which AT devices/services are needed.
Primary Purpose for Which AT is Needed
Response
Education
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
4. Have not made a decision (d)
5. Subtotal
6. Nonrespondent (d)
7. Total
8. Performance on this measure

Employment

Community
Living

Total

System-generated

System-generated System-generated

System-generated

NOTES: Items marked (n) are included in numerator. Items marked (d) are included in denominator.
Non-respondents are included in the denominator for calculation of performance. (System will generate
an error message if total reported in column on far right does not equal total reported in Section A.)

F. Customer Satisfaction

Use data from customer surveys (which include an item about satisfaction) to complete the
table below for all customers served by device demonstration.
Customer Rating of Services
Highly satisfied
Satisfied
Satisfied somewhat
Not satisfied

Number of Customers

Percent
System-generated
System-generated
System-generated
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 B.)

G. Notes

Describe any unique issues that may affect your data in this section (e.g., types of
participants that may appear to be underrepresented because they receive demonstration services
from another organization, types of devices/services that are not demonstrated because those
demonstrations are available from another source, issues related to use of distance education
mechanisms to deliver demonstrations, or issues related to dissatisfaction (e.g.; consumer may be
dissatisfied because they assumed the AT Program could purchase the device for them).

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Device Demonstrations

(Narrative item)

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National Outcome Measures (ACL targets for national aggregate data)
Performance measure outcomes from each of the four state level activities are summed in the
following tables for one overall acquisition and one overall access performance measure
percentage. ACL began using this overall performance measure percentage for aggregate AT
Program evaluation in FY18. The ACL National Target identified in each performance measure
table is applied to summed national aggregate data for all 56 Section 4 grantees not to individual
grantees as a met/not met criteria. It is provided in the acquisition and access performance
measure tables below for informational purposes to be used at the discretion of the grantee.
The consumer satisfaction rating and response rates from each of the four state level activities
are also summed in the last table. ACL began using an overall consumer satisfaction and
response rate for aggregate AT Program evaluation in FY18. The ACL National Targets
identified in the consumer satisfaction rating and response rate table is applied to summed
national aggregate data for all 56 Section 4 grantees not to individual grantees as a met/not met
criteria. It is provided in the consumer satisfaction tables below for informational purposes to be
used at the discretion of the grantee.
Overall Acquisition Performance Measure

The overall acquisition performance measure is the sum of State Financing, Reuse and Shortterm Device Loan (all purposes except decision-making) data and is used ONLY for national
aggregate outcome purposes. This overall calculation includes only lines 1 and 2 in the
numerator as it represents the percentage of recipients who were unable to afford or otherwise
obtain the AT needed without the State AT Program.
Response
1. Could only afford the AT
through the statewide AT
program
2. AT was only available
through the statewide AT
program
3. AT was available through
other programs, but the system
was too complex, or the wait
time was too long
4. Subtotal
5. None of the above
6. Subtotal
7. Nonrespondent
8. Total
9. Performance on this measure
10. ACL National Target

Primary Purpose for Which AT is Needed
Education

Employment

Community Living

Total

System-generated

System-generated
85%

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Overall Access Performance Measure

The overall access performance measure is the sum of Short-term Device Loan (decision-making
purpose) and Device Demonstration performance measure data.
Primary Purpose for Which At is Needed
Response
1. Decided that an AT device/service
will meet needs
2. Decided that an AT device/service
will not meet needs
3. Subtotal
4. Have not decided
5. Subtotal
6. Nonrespondent
7. Total
8. Performance on this measure
9. ACL National Target

Education

Employment

Community Living

Total

System-generated System-generated

System-generated System-generated
90%

Overall Satisfaction Rating

The overall satisfaction rating is the sum of all four state level activities (State Financing, Reuse,
Short-term Device Loan and Device Demonstration) satisfaction data. It represents the number
of program beneficiaries who are highly satisfied or satisfied with state level activity services
they received from the State AT Program.
Customer Rating of Services
Highly satisfied and satisfied

Percent
System-generated

ACL National Target
95%

Response rate

System-generated

90%

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Educational /Training Activities
Outline
Overview of Activities Performed
A. Educational/Training participants: Number and types of participants; geographical distribution
B. Educational/Training topics
C. Description of educational/training activities
D. Notes
Section 4f requirements: Educational Activities/Training
1. “the number and general characteristics of individuals who participated in educational activities …
(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 educational activities”
3. “to the extent practicable, the geographic distribution of individuals who participated in the
educational activities.”
Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that
statewide AT programs provide educational activities and technical assistance to assist students with
disabilities who receive transition services under IDEA and adults with disabilities maintaining or
transitioning to community living. Section e also requires that at least 5% of the money spent on State
Leadership activities be used for transition activities.

The AT Act of 1998, as amended in 2004 provided a combined description of training and
technical assistance. The 21st Century Assistive Technology Act, enacted 12/23/2022,
reauthorized the program and changed the term “training” to “educational activities.” In general,
education provides theoretical knowledge while training provides practical skills, and the APR
has historically defined training as inclusive of both. Following is guidance on what activities to
report in this section and how to distinguish educational/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 educational/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 an educational/training event or
a technical assistance initiative.
Educational/training activities are instructional events, usually planned in advance for a
specific purpose or audiences, which are designed to increase participants’ knowledge, skills,
and competencies regarding AT. Such events can be delivered to large or small groups, inperson, or via telecommunications or other distance education mechanisms. In general,
participants in educational/training activities can be individually identified and could complete
an evaluation of the educational/training event. Examples of educational/training activities
include classes, workshops, and presentations that have a goal of increasing skills, knowledge,
and competency, as opposed to something intended only to increase general awareness of AT.
Distinguishing Educational/Training Activities from Public Awareness Activities

Educational/training activities have more depth and breadth than public awareness activities
and are focused on skill building and competency development. If the purpose of an
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educational/training session is to create awareness, the session should be classified as a public
awareness activity. In general, participants in educational/training events can be individually
identified, while in awareness activities, it may not be possible to identify each participant
individually.
Working with individual consumers on how to use a particular AT device or troubleshooting
problems with devices should be reported under “Information and Assistance.”
Distinguishing Educational/Training Activities from Technical Assistance

Educational/Training activities are designed to teach, present, or guide individuals 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 typically
involves multiple contacts and interactions over an extended period.
In some cases, educational/training activities may be a component of technical assistance.
Educational/training activities provided as part of technical assistance can be reported here, but
only if the educational/training activity was supplemented by other technical assistance activities.
If an educational/training activity was the only technical assistance service provided, it can be
reported as either educational/training or technical assistance, but not both.
Overview of Activities Performed

Educational/Training activities are required and must be reported as described below.
A. Educational/Training Participants: Number and Types of Participants; Geographical
Distribution

1. Enter the number of educational/training participants by type. The participant may selfdetermine the appropriate descriptor for themselves, or such information may be derived
from other educational/training event records. Use “unable to categorize” when no data
can be obtained on type of participant.
Type of Participant
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
Unable to Categorize
Total

Number

2. Enter the number of individuals who participated in educational/training events, by the
Rural Urban Continuum Code (RUCC) of the participant’s county. For a consumer, you
determine the RUCC by the county in which he or she resides. For a representative, you
determine the RUCC by the county in which they generally provide services.

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Participants for whom you cannot determine a county are counted in “Unknown.” For
additional guidance on the RUCC, refer to the Instruction Manual.
Metro (RUCC 1-3)

Non-Metro (RUCC 4-9)

Unknown

TOTAL

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

Educational/Training Topics

Enter the number of participants by the primary content of the educational/training event
organized into the following categories:
1. AT products and services, which includes subcategories of AT types.
2. AT funding, policy, and practice, which includes subcategories of common topics in this
category and space other related AT topics.
3. Information and Communication Technology (ICT) Accessibility including web access,
software accessibility, procurement of accessible ICT, and similar. For participants in
this topic, you will need to collect a performance measure, see below.)
4. Combination of AT products and services, AT funding, policy, and practice and/or
IT/Telecommunications. (Use this category only when absolutely necessary.)
5. Transition, including transition from school to work or postsecondary education and
transition to community living. (Use this category for ALL transition activities even if
they could be reported as AT Products/Services, AT Funding/Policy, etc.)
Primary Topic of Educational/Training Activities
1. AT Products/Services
Focused on AT: such as instruction to increase skills and competency in using
AT, and integrating AT into different settings

Number of
Educational/Training
Participants

2. AT Funding/Policy/ Practice
Focused on funding sources and related laws, policies, and procedures
required to implement and deliver access to AT devices/services and related.
3 Combination of 1 and 2 above
AT Products/Services and AT Funding/ Policy/Practice
4.Information and Communication Technology (ICT) Accessibility
Focused on accessible information and communication technology (ICT)
including web access, software accessibility, procurement of accessible ICT
5. Transition
Focused on education transition (school to work or post-secondary education
and early intervention (birth to 3) to school aged (3 -21) and community
transition (maintaining or transitioning to community living). (Note: A number
must be reported here unless transition technical assistance is reported.)
Total

A performance measure
must be collected for these
participants
If a number is reported
here, a description must be
provided in C.2. below.

System-generated

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

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B. Description of Educational/Training Activities

1. Briefly describe one innovative or high-impact educational/training activity conducted
during this reporting period. Note who conducted the event (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 event. In another sentence,
summarize the positive result or intended impact of the event. Do not include overall
descriptions of conferences held unless the conference had a unique purpose/outcome.
Narrative item- Each narrative is limited to 3000 characters.

2. Briefly describe an educational/training activity related to transition conducted during
this reporting period. Note who conducted the event (e.g., expertise of staff) and
characteristics of the audience (including number that attended). In one sentence,
describe the topic, content, and/or approach of the event. In another sentence, summarize
the positive result or intended impact of the event. Do not include overall conference
descriptions absent a unique purpose/outcome. This section must be completed unless
you report transition technical assistance activities. If this section is completed, an
associated number of participants must be reported in Section B Row 5.
Narrative item- Each narrative is limited to 3000 characters.

3. Briefly describe an educational/ training activity related to Information and
Communication Technology (ICT) accessibility conducted during this reporting period.
Note who conducted the event (e.g., expertise of staff) and characteristics of the
audience (including number that attended). In one sentence, describe the topic, content,
and/or approach of the event. In another sentence, summarize the positive result or
intended impact of the event. This section must be completed if you have attendees
reported in the ICT accessibility topic area in Section B Row 4.
Narrative item- Each narrative is limited to 3000 characters.

D. Information & Communication Technology (ICT) Accessibility Performance Measure
Outcome/result from ICT Accessibility Education/Training Received Number
ICT accessibility procurement or development policies, procedures, or practices
will be improved or better implemented to ensure accessibility. (n,d)
Education/Training or technical assistance activities will be developed or
implemented to ensure accessibility of ICT. (n,d)
No known outcome at this time. (d)
Non-respondent (d)

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

System-generated
System-generated

E. Notes

Describe any unique issues that may affect the data in this section, (e.g. why particular
topics or audiences were emphasized or were not included during this reporting period).
(Narrative item)

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Technical Assistance
Outline
Overview of Activities Performed
A. Frequency and nature of technical assistance
B. Description of technical assistance activities
C. Notes
Section 4f requirements:
Technical Assistance
“The frequency of provision and nature of technical assistance provided to State and local agencies
and other entities.”
Transition: No explicit reporting requirement in Section 4f, but Section 4e includes requirement that AT
programs provide educational/training activities and technical assistance to assist students with
disabilities who receive transition services under IDEA and adults with disabilities maintaining or
transitioning to community living. Section e also requires that at least 5% of the money spent on State
Leadership activities be used for transition activities.

The 21st Century Assistive Technology Act provides a combined description of
educational/training and technical assistance activities. Additional descriptions of technical
assistance are provided below, along with guidance for distinguishing technical assistance from
public awareness and educational/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 educational/training are reported in that section.
Reminder- each Statewide AT Program must report on at least one transition activity related to
school transition (e.g., secondary school to post-school) AND one transition activity related to
community living (e.g. maintaining or transitioning to community living). The activity reported
may be either an educational/training event or a technical assistance initiative.
Distinguishing Technical Assistance from Information & Assistance

Technical assistance is provided to agencies or other organizations, not to individuals.
Intensive support provided to an individual, for example assisting an individual troubleshoot
problems with an AT device or address a funding issue, is reported under information and
assistance. Technical assistance typically includes multiple contacts/interactions over an
extended period with an agency or organization. Less intensive support services, including
single-contact requests for information or limited assistance from agencies or organizations
should also be reported under information and assistance.

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Distinguishing Technical Assistance from Educational/Training Activities

Educational/Training activities are designed to teach, present, or guide individuals in order
to impart knowledge, skills, and competencies to individuals, while technical assistance may be
designed to help entities (not individuals) improve their policies, practices, and procedures and
generally involve problem solving.
In some cases, educational/training activities may be a component of technical assistance.
Educational/Training events provided as part of technical assistance can be reported in the
training section, but only if the educational/training activity was supplemented by other technical
assistance activities. If an educational/training activity was the only technical assistance service
provided, it can be reported as either educational/training or technical assistance, but not both.
Overview of Activities Performed

Technical Assistance activities are required, and all activities should be reported in the aggregate
in Section A. One TA activity must be described in Section B and a transition TA activity must
be reported unless a transition educational/training activity was reported.
A. Frequency and Nature of Technical Assistance

Complete this section summarizing all major technical assistance activities that you conducted.
Indicate the percentage of total technical assistance provided by the type of program or agency
receiving the technical assistance. Use the person hours invested in each technical assistance
activity to report the percentage by type of program or agency. For example, if you conducted
two major TA activities this reporting period with 90 total person hours for an activity related to
education and 50 person hours for an activity related to employment, you would report 64% in
education and 36% in Employment.
Program or agency receiving technical assistance

Percentage of all TA

Education
Employment
Health, Allied Health, Rehabilitation
Community Living
Technology (Information Technology, Telecommunications,
Assistive Technology)
Total

Must equal 100%

B. Description of Technical Assistance Activities

In Item 1 below, describe an innovative or high-impact technical assistance activity that is
not related to transition. For this item, choose a technical assistance activity that had an
outcome. In Item 2 below, describe a technical assistance activity that is related to transition.
The transition technical assistance activity is not required to have an outcome.
1. Describe in detail one innovative or high-impact technical assistance activity conducted
during this reporting period. Note who provided the technical assistance (e.g., type of
expertise of staff) and characteristics of the recipient agency. In two sentences: (1) describe

Page 37

the topic, content, and/or approach of the technical assistance; and (2) summarize the
positive result or impact of the technical assistance.
Narrative item- Each narrative is limited to 3000 characters. .

2. Briefly describe one technical assistance activity related to transition conducted during
this reporting period. Note who provided the technical assistance (e.g., type of expertise of
staff) and characteristics of the recipient agency. In two sentences: (1) describe the topic,
content, and/or approach of the technical assistance; and (2) summarize the positive result or
impact of the technical assistance. NOTE: This section must be completed unless a
transition educational/training activity is reported.
Narrative item- Each narrative is limited to 3000 characters.

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)

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Public Awareness and Information and Assistance
Outline
Overview of Activities Performed
A. Public awareness activities
B. Information and Assistance
C. Notes
Section 4f requirement: “the number of individuals assisted through the public awareness activities and
statewide information and referral system”.

Public awareness activities are designed to reach large numbers of people, including
activities such as public service announcements, radio talk’s shows and news reports, newspaper
stories and columns, newsletters, brochures, and public forums. Actual numbers of information
recipients are often difficult to know for certain, but should be reported when known, and in
other cases estimated as accurately as possible. Public awareness activities should be reported, as
accurately as possible, in Part A of this section.
Information and assistance include provision of information and supports to individuals and
provision of referrals to other entities. All these activities may be provided in person, over the
telephone, via email, or other effective communication mechanisms.
Distinguishing Information and Assistance from Device Demonstration Referral

In this section, report only on referrals resulting from information dissemination activities,
such as calls to a 1-800 number or e-mails. Referrals resulting from device demonstrations
should be reported under device demonstrations.
Distinguishing Public Awareness from Educational/Training Activities

The intended outcome of an activity should determine whether it is reported under public
awareness or educational/training activities. Include presentations made for the purpose of
general awareness under public awareness. Do not include sessions with the intended outcome of
participants applying new knowledge or skills in addressing AT device/service issues (which
should be reported under educational/training activities).
Overview of Activities Performed

Public awareness and information and assistance activities are required and must be reported.
A. Public Awareness Activities

In this section report on one or two high impact public awareness activities. This can
include newsletters (paper or digital), listservs, blogs, social media, web-based information,
public service announcement via television, radio, online broadcasts, podcasts, internet
streamed or live presentations, or many other mechanisms designed to disseminate
awareness level information to a wide audience. Please remember that presentations
reported in this section are for the purpose of general awareness. Educational/training
sessions with the intended outcome of participants applying new knowledge or skills in
addressing AT device/service issues should be reported as an educational/training activity.
(NOTE: Purchasing promotional items is not allowable under OMB Circular direction and
as such should not be reported in this section as a public awareness activity.)

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Describe in detail at least one and no more than two innovative or high-impact public
awareness activities conducted during this reporting period. Highlight the content/focus of
the awareness information shared, the mechanism used to disseminate or communicate the
awareness information, the numbers and/or types of individuals reached, and positive
outcomes resulting from the activity. Also, please identify any partnerships that were used
to support the awareness activity (e.g., partnering with AAAs to disseminate information to
older adults, with CILs to disseminate information to individuals with disabilities, with
professional associations (OT/PT/SLP), etc.) If quantitative numbers are available regarding
the reach of the activity, please provide those; however, quantitative data is not required.
(Narrative item) Each narrative is limited to 3000 characters.
(Narrative item) Each narrative is limited to 3000 characters.
B. Information and Assistance

Information and assistance (I&A) activities are those in which the AT program responds to
requests for information and/or puts individuals in contact with other agencies, organizations, or
companies that can provide them with needed information on AT products, devices, services, or
funding sources or provides intensive assistance to individuals about AT products, devices,
services, or funding sources. This information may be provided in person, over the telephone, via
email, or by some other communication mechanism.
In the table below report the number of individuals to whom you provided information and
assistance services by type of individual or entity (see instructions for classification system
explanation) and by the content of the information and assistance provided. To the extent
practicable each unique request for information and assistance should be counted only once. For
the content of the I&A provided, differentiate between -• Information and assistance about specific AT products, devices, or services, or selecting
an AT product, device, or service; and
• Information and assistance that addresses obtaining funding for or otherwise acquiring
AT devices and services or providing AT policy/practice information.
Types of Recipients of
Information and Assistance
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
Unable to Categorize
Total

AT Device/
Service

AT Funding/
Policy/Practice

Total
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated
System-generated

System-generated

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In addition to reporting the quantities of individuals you provided information and assistance to,
it is also helpful to know how these individuals learned about the state AT program.
Understanding how people are learning about the state AT program enables programs to enhance
and refine public awareness and outreach activities. Please provide a narrative description that
reflects a qualitative assessment of outreach and education and the types of referrals that
increased referrals to the state AT program because of that effort. The description should
include:
•

Unique strategies and/or partnerships used in the outreach strategy that were particularly
helpful in increasing referrals

•

Information about the referral source types that were increased as a result of the outreach
activity (e.g., increased referrals from agencies such as Area Agencies on Aging (AAA),
Centers for Independent Living (CIL), etc. and/or from other types of service providers,
such as health care practitioners, educators, rehabilitation counselors, etc.) Numeric data
is helpful but not mandatory in describing the increased referral results.

(Narrative item)
It is also helpful to have information about the types of referral sources that are referring people
to the AT program for Information and Assistance. The information reported will be valuable in
understanding the types of referral sources and identifying opportunities to build and/or
strengthen partnerships to expand awareness of state AT programs and serve those with
disabilities across all geographies in a state. In the box below please provide a narrative
description of the types of entities/practitioners that refer people to the AT program. It is helpful
to include estimates on the percentage of the total referrals coming from each referral source in
the narrative and the geographical reach of these referral sources. For example, we work with all
30 libraries across the state resulting in statewide coverage and regularly receive referrals from
all of them. Approximately 25% of our total referrals for information and assistance come from
libraries.
Narrative Item
C. Notes: Describe any issues with your data in this section.

(Narrative item)

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Coordination/Collaboration and State Improvement Outcomes
Outline
Overview of Activities Performed
A. Coordination/Collaboration Partnership Initiatives
B. State improvement outcome
To improve access to AT across a state, it is understood and expected that AT Programs will
coordinate and collaborate with other public and private entities in terms of receiving referrals, sharing
information, serving on advisory board, etc. and will provide technical assistance to a variety of
agencies and entities throughout the reporting period. Outcomes of state improvements initiatives
must result in policy, practice or procedure improvements beyond those associated with or already
reported in previous state-level and state leadership coordination and collaboration sections.
Section 4f requirements: “the outcomes of any improvement initiatives carried out by the State as a
result of activities funded under this section, including a description of any written policies, practices,
and procedures that the State has developed and implemented regarding access to, provision of, and
funding for, assistive technology devices, and assistive technology services, in the contexts of
education, health care, employment, community living, and information technology and
telecommunications, including e-government.”

Overview of Activities Performed

Coordination/Collaboration and Partnerships are essential in responding to increased demand to
acquire AT, conduct educational/training activities, demonstrations, and short-term loans.
Reporting partnership activities enables other programs to identify partnership activities that can
be replicated to increase access to and acquisition of AT. Partnerships can help reach a broader
universe of people with disabilities across all geographies and points of access in a state. This is
particularly important in larger states and states with rural geographies where people with
disabilities are not likely to have easy access to the physical location of an AT program.
Coordination/Collaboration partnership initiative reporting is required. State AT programs
should have a multitude of partnerships. The AT Act requires goals in a variety of areas and the
2022 reauthorization added the area of “access to tele assistive technology to aid in
the access of health care services, including mental health and substance use disorder
services.” A partnership in that area could be reported in this section using the focus area
of Information and Communication Technology/Remote Connectivity.
Please report at least one and up to two partnerships that increase access to AT for this reporting
period. Examples of partnership initiatives include collaborating with the state aging network to
provide Assistive Technology toolkits for each Area Agency on Aging or teaming up with the
state education agency to distribute AT needed for remote learning or partnering with Centers for
Independent Living to increase awareness and access to assistive technology for people with
disabilities.
State improvement outcome reporting is optional, but ACL strongly emphasizes the importance
of partnerships to expand the AT programs’ reach to unserved target populations and reporting
this information will improve the ability to replicate successful partnerships in other states and
improve overall program outcomes. You may report up to two MAJOR state improvement
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outcomes for this reporting period. (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.)
A. Coordination/Collaboration Partnership Initiatives

Complete this section for each coordination/collaboration partnership initiative to be reported.
1. As concisely as possible, describe the partnership initiative. What activities/services
were provided? Who are the major collaborating organizations and what is their role?
Who is served/benefited? What funding was used to implement the initiative? (Narrative
field)
2. As concisely as possible, describe the measurable results of the initiative and any lessons
learned. How did access to AT change because of the
coordination/collaboration/partnership? How did awareness of AT change because of
the partnership? How did the reach of the state AT program change because of the
partnership? What made the partnership successful? What would you change or wish
you had done differently? Provided funding/resources are available, will the initiative
continue or is this a one-time event? What advice would you give for replication of the
initiative? Please include URL for initiative if available. (Narrative field)
3. What focus areas(s) were addressed by the initiative? Drop-down list: Education,
Employment, Housing/Home Automation, Transportation, Community Participation and
Integration, Recreation/Leisure, Health, Aging, Transition (school to work or
congregate care to community), Aging and Disability Network/No Wrong Door,
Veterans, Information and Communication Technology/Remote Connectivity, Other.
4. What AT Act authorized activity(s) were addressed? Drop-down list: SFA, Reuse,
Device Loan, Demo, Educational/Training Activities, TA, I&A, PA.
B. State Improvement Outcomes

Complete this section for each MAJOR state improvement outcome to be reported.
1. In one or two sentences, describe the outcome. Be as specific as possible about exactly
what changed during this reporting period because of the AT program’s initiative.
(Narrative field)
2. In one or two sentences, describe the written policies, practices, and procedures that
have been developed and implemented because 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)
3. What was the primary area of impact for this state improvement outcome? Drop-down
box: Education – Employment -- Health, Allied Health, Rehabilitation -- Community
Living -- Technology (Information Technology, Telecommunications, and AT).
B

State Improvement Outcome

If you have a second MAJOR outcome to report, this section will need to be completed with
items 1 through 3 above.

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Additional and Leveraged Funds
Outline
Overview of Activities Performed
A. Leveraged Funding for State Plan Activities (Previously Reported)
B. Leveraged Funding for Activities Not in State Plan (not previously reported)
C. Notes
Section 4f requirement: “(x) the source of leveraged funding or other contributed resources, including
resources provided through subcontracts or other collaborative resource-sharing agreements, from
and with public and private entities to carry out State activities described in subsection (e)(3)(B)(iii), the
number of individuals served with the contributed resources for which information is not reported under
clauses (i) through (ix) or clause (xi) or (xii), and other outcomes accomplished as a result of such
activities carried out with the contributed resources”

Overview of Activities Performed

Did you have Additional and Leveraged Funding to report? (Check yes or leave unchecked).
In this section, provide information on funding that has been leveraged to support statewide AT
Program activities as included in your State Plan for AT. Report only actual dollars leveraged.
Do NOT report in-kind contributions. Do NOT report ongoing AFP endowments or matching
funds. Additional and leveraged funding reported in this section is NOT necessarily considered
program income under federal guidelines.
A. Leveraged Funding for State Plan Activities

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. The definitions of each
category are as follows:
Federal – Grants that are received directly by the State AT Program from federal agencies, e.g.,
HHS/ACL, ED/OSEP, etc.
Public/State Agency – Grants, contracts, memorandum of understanding and similar agreements
between the State AT Program and state or other public agencies with associated dollars, e.g.,
federal flow through, dedicated state funds, etc.
State Appropriations – State dollars/general state funds directly appropriated for use by the State
AT Program;
Private – Grants, contracts, memorandum of understanding and similar agreements with private
agencies funded with dollars that can be of any type.
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.
Identify if data associated with this leveraged funding has been reported or not. For most
leveraged funding entries, the number of individuals served, or other outcome data should have
already been reported in the appropriate previous sections of this Annual Performance Report.
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However, there may be rare extenuating circumstances in which a program reports leveraged
funding in this section but is unable to report data in the associated section of the APR, e.g., a
AT educational/training event funded by an external source did not allow for information to be
collected in a way that could be reported in the educational/training activities section of the APR.
In that case, you should indicate that data was not reported and provide a narrative explanation.
Fund Source (select one)
▪
▪
▪
▪

Federal
Public/State Agency
State Appropriations
Private

Amount

Use of Funds (select one)
▪
▪
▪
▪
▪
▪
▪

State Financing
Educational/Training
Reuse
Technical Assistance
Demonstration
Public Awareness/I&A
Device Loan

Data Reported (select one)
▪
▪

Yes, data was reported in
previous section of APR
No, data was not reported
in previous section of
APR and an explanation
is provided

option to repeat row data

For any leveraged funding reported above for which data could not be reported, please describe the

extenuating circumstances that precluded data from being reported and efforts to remediate the
situation in future reporting periods.
(Narrative item)

B. Notes

Describe any unique issues with your data in this section including any leveraged funding your
program received that was used to support activities authorized by the AT Act, but those
activities were not included in your State Plan for AT with an explanation of why such activities
were not part of the State Plan.
(Narrative item)

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Data Collection Instrument
Access Performance Measure
TO BE COMPLETED BY PROGRAM STAFF
Services provided:
Device demonstration
OR
Device loan (decision-making purpose)
Date service delivery was completed: __________
Date this form was received: ____________________

ID (optional) ____________

Please answer the following questions about the services you received from the (insert name of
statewide AT program or its subcontractor). We need this information to provide high quality
services and to meet the requirements for receiving federal funding.
1. The primary purpose for which I need (or the person I represent needs) an AT device or
service is related to:
(Please mark only one answer.)
Education—participating in any type of educational program
Community living—carrying out daily activities, participating in community activities,
using community services, or living independently
Employment—finding or keeping a job; getting a better job; or participating in an
employment training program, vocational rehabilitation program, or other program
related to employment
2. What kind of decision about AT devices or services were you (or someone you represent)
able to make after your device demonstration or device loan?
(Please mark only one answer.)
_____
_____
_____

Decided that AT device(s) or service(s) will meet my needs (or the needs of someone I
represent).
Decided that AT device(s) or service(s) will not meet my needs (or the needs of
someone I represent).
Have not decided.

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Data Collection Instrument
Acquisition Performance Measure (SFA and Reuse)
TO BE COMPLETED BY PROGRAM STAFF
ID (optional) ____________
Services provided:
“State financing” services—including financial loan, assistance in accessing funds for AT
devices/services, assistance in obtaining AT devices and services at reduced cost or
free, or other related services
Device reuse— received an AT device through a device exchange, reassignment/refurbish
or repair or open-ended loan program
Date service delivery was completed: __________
Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of
statewide AT program or its subcontractor). We need this information to provide 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 choose to obtain AT devices/services 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

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Data Collection Instrument
Acquisition Performance Measure (Device Loan)
TO BE COMPLETED BY PROGRAM STAFF
ID (optional) ____________
Short-term device loan purposes:
Providing loaner equipment during device repair or while waiting for funding
Providing an accommodation for a time-limited event
Conducting educational/training or other professional development activity
Date service delivery was completed: __________
Date this form was received: ____________________

Please answer the following questions about the services you received from (insert name of
statewide AT program or its subcontractor). We need this information to provide 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 choose to borrow AT devices/services from our program?
(Please mark only one answer.)
_____ I could only afford to borrow the AT through this program. (I could not afford to rent
or borrow it through other programs.)
_____ The AT was only available to me through this program. (I am not eligible or there
is no other rental or device loan program available; or the specific device(s) I
needed are not loaned by other programs.)
_____ The AT was available to borrow from other programs, but the system was too
complex or the wait time was too long. (I couldn’t borrow device(s) in a timely
manner.)
_____ None of the above

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Data Collection Instrument
Information and Communication Technology Accessibility
Performance Measure
TO BE COMPLETED BY PROGRAM STAFF
IT/Telecom Educational/Training Session
Date session was provided: __________
Date this form was received: ____________________

ID (optional) ____________

Please answer the following question about the training you participated in provided by (insert
name of statewide AT program or its subcontractor). We need this information to provide highquality services and to meet the requirements for receiving federal funding.
What do you anticipate will be the primary outcome of your participation in this
educational/training event on Information and Communication Technology (ICT) accessibility?
(Please mark only one answer that best represents the primary outcome.)
_____ ICT (web, software, etc.) procurement or development policies, procedures, or
practices will be improved or better implemented to ensure accessibility
_____ Educational/Training activities will be developed/implemented to ensure
accessibility of websites, software, or other ICT (web, software, etc.)
_____ Outcome is unknown currently.

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Survey Instrument Consumer Satisfaction

Survey Instrument
Customer Satisfaction

TO BE COMPLETED BY AT PROGRAM STAFF
ID (optional) __________
Services provided:
Device demonstration
Device short-term loan
State financing programs —including financial loan, direct provisions of AT or acquisition
of AT for a reduced cost.
Device reuse programs —including device exchange, or refurbish/repair with
reassignment or open-ended loan
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

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File Type	application/pdf
File Modified	2024-05-01
File Created	2024-05-01