Association of Assistive Technology Act Programs (ATAP)

»» Return to NISAT | Downloadable Word (DOC) Files »»

Translate This Web Page (Google Translation Service)

From: Arabic Bulgarian Catalan Chinese Croatian Czech Danish Dutch English Filipino Finnish French German Greek Hebrew Hindi Indonesian Italian Japanese Korean Latvian Lithuanian Norwegian Polish Portuguese Romanian Russian Serbian Slovak Slovenian Spanish Swedish Ukrainian Vietnamese To: » Arabic Bulgarian Catalan Chinese (Simplified) Chinese (Traditional) Croatian Czech Danish Dutch English Filipino Finnish French German Greek Hebrew Hindi Indonesian Italian Japanese Korean Latvian Lithuanian Norwegian Polish Portuguese Romanian Russian Serbian Slovak Slovenian Spanish Swedish Ukrainian Vietnamese

Data Collection Instrument
Acquisition Performance Measure

TO BE COMPLETED BY PROGRAM STAFF ID (optional) ____________ Services provided: “State financing” services—including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and services at reduced cost or free, or other related services Device exchange—received an AT device through a device exchange program Device recycling—received an AT device through a device recycling program OR Open-ended loan – received an AT device through an open-ended loan Date service delivery was completed: __________ Date this form was received: ____________________

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

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

(Please mark only one answer.)

Education—participating in any type of educational program

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

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

2. Why did you chose to obtain an AT device/service from our program?

(Please mark only one answer.)

_____ I could only afford the AT through this program. (I could not afford it through other programs.)

_____ The AT was only available to me through this program. (I am not eligible or don't qualify for other programs, the AT is not covered by other funding sources or the specific device I needed is not provided by other programs.)

_____ The AT was available to me through other programs, but the system was too complex or the wait time was too long. 

_____ None of the above

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.