Association of Assistive Technology Act Programs (ATAP)

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Data Collection Instrument
Access Performance Measure

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

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

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

(Please mark only one answer.)

Education—participating in any type of educational program

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

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

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

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

(Please mark only one answer.)

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

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

_____ Have not made a decision.

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information is 1820-0572. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington DC, 20202. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to Mr. Jeremy Buzzell, Rehabilitation Services Administration, U.S. Department of Education, Potomac Center Plaza, Room 5025, 400 Maryland Ave. SW, Washington, DC, 20202-2800.