0 Training: General Training is not public awareness – training has more depth and breadth. If the purpose is to create awareness, the training session is public awareness. Working with individual consumers on devices or troubleshooting problems is “Individual Assistance” under Public Awareness.

1 Training: General  Training is provided to individuals (even if they attend as a group) and increases skills/competencies.  Technical assistance is provided to agencies and involves problem solving  Technical assistance may include training.  If you train as part of TA it can be included here – but if training was the ONLY TA activity, you don’t include it in TA as well

2 Training: Geographic Distribution Geographic distribution of those to whom you provided training – not where you provided the training. For consumers, use county of residence. For professionals, use county in which the professional provides services.

3 Training: Participants Type of Participant Area of Residence Total Metro RUCC 1-3 Urban RUCC 4-7 Rural RUCC 8-9 Unknown Individuals with disabilities System- generated Family members, guardians, and authorized representatives System- generated Educational organizations System- generated Employers and businesses System- generated Providers of employment and/or training services System- generated Health, allied health, and rehabilitation organizations System- generated Others System- generated Unable to categorize System- generated Total System- generated

4 Training: Training Topics Primary Topic of Training Number of Training Participants 1. AT Products/Services Training focused on AT: such as instruction to increase skills and competency in using AT, and integrating AT into different settings Computers and related Daily living Environmental adaptations Hearing Learning, cognition. and developmental Mobility, seating and positioning Recreation, sports, and leisure Speech communication Vehicle modification and transportation Vision Other (specify) 2. AT Funding/Policy/Practice Funding sources and related laws, policies, and procedures Accessible IT, telecommunications, voting, or textbooks Other funding/policy/practice topic (specify) 3. Combination of AT Products/Services and AT Funding/Policy/Practice 4. Transition Education transition (including school to work or postsecondary education and Part C to Part B) Community transition (adults to community living) Other (specify) Other Topic(Specify) TotalSystem- generated

5 Training: Notes Describe one innovative or high-impact training* activity conducted during this reporting period. Describe one transition training conducted during this reporting period. Who conducted the training? Who attended (including number)? What was the topic, content, and/or approach? What was the result? Do not include overall descriptions of conferences.

6 Training No performance measures No performance measures No customer satisfaction No customer satisfaction Coordination and Collaboration Coordination and Collaboration Notes Notes

7 Technical Assistance: General TA is provided to agencies, not individuals. Troubleshooting devices for individuals is “Individual Assistance” under Public Awareness. Training focuses on increasing skills and is done for individuals (even in groups) – TA is problem solving for an entity. If training was the only kind of TA you provided, this is training and not TA. If training was only one part of TA, it can be both TA and training.

8 TA: Frequency and Nature 1. How many major technical assistance activities did you conduct during the reporting period? ___ (Respondents who enter “1” or more will receive balance of section.) (If Item 1=0) You can see a read-only. Complete this section for each major technical assistance activity that you conducted. If you have more than one activity to report, you will need to complete this section more than once. After you have completed your first entry, you will be given an opportunity to repeat this section in order to report additional activities.

9 TA: Frequency and Nature 1. Recipient of technical assistance: Radio buttons for “check all that apply”: (1)education agency or organization; (2)employer or business; (3) provider of employment/training services; (4) public or private agency or organization not otherwise classified above; (5) manufacturer/ vendor; (6) other (specify)

10 TA: Frequency and Nature 3. For this technical assistance activity, identify the policy expertise areas and product/service expertise areas that were addressed. If the technical assistance activity included both policy and product/service expertise, select both. Note that mandatory transition activities that are technical assistance activities are reported here under product/service expertise. Mandatory transition activities that are training activities are reported in the training section. Radio buttons for “check all that apply”: (1) policy area; (2) product/service area (If policy area) Identify the policy areas on which the technical assistance* focused. Choose all that apply. Radio buttons: (1) ADA/504; (2) IDEA Part C; (3) IDEA Part B; (4) Section 508 and Section 255; (5) WIA/Rehabilitation Act/VR; (6) Medicaid; (7) Medicare; (8) Private insurance; (9) HAVA; (10) Older Americans Act; (11) SSI/SSDI/Work Incentives; (12) Olmstead (13) other (specify) (If product/service area) Identify the product/service areas on which the technical assistance* focused. Choose all that apply. Radio buttons: (1) Web accessibility; (2) accessible IT procurement; (3) AT purchasing (cost-effective options);(4) accessible voting systems; (5) AT eligibility determinations; (6) AT personnel development; (7) AT resource allocation; (8) AT service delivery options; (8) AT legislation/policy development; (9) specific AT device assistance; (10) transition–education; (11) transition–community living; (12) other (specify)

11 TA: Frequency and Nature 4. Duration of technical assistance* during this reporting period: Drop-down box: (1) less than 3 months; (2) 3 to 5 months; (3) 6 to 8 months; (4) 9 to 12 months; (5) other (specify) 5. Approximate number of person hours expended by AT program staff to deliver the technical assistance:* (Numeric field) 6. Do you have additional activities to report? If so, select “Yes” and the system will repeat this section. If you select “no,” it will take you to the next section of the reporting form. Drop-down box: (1) yes; (2) no (Respondents who choose “1” will repeat Items 1 through 5.)

12 TA Coordination and Collaboration Description of TA Activity:  One high-impact or innovative  One transition

13 Public Awareness: General Public awareness is intended to reach large audiences and is not as in-depth as training. Public awareness includes: 1. Public Awareness 2.Information Dissemination Information and Referral (not to be confused with referral related to device demonstration!) Information and Referral (not to be confused with referral related to device demonstration!) Individual Assistance Individual Assistance

14 Public Awareness Activities Public Awareness Activity Estimated Number of Individuals Reached Newsletters Other print materials Listservs Internet information PSA/radio/TV Presentations/expos/conferences* Other Total

15 Public Awareness: Individual Assistance Report the number of individuals to whom you provided individual assistance, by primary type of information/assistance provided. Provide a count of the number of individuals assisted, rather than the number of contacts made. If one person made three phone calls in one week, that should be counted as one person assisted, not three. If the three phone calls are for different purposes, select the primary purpose.

16 Public Awareness: Individual Assistance Individuals Assisted AT Device/Service At Funding Related Disability Topics Total Individuals with disabilities System- generated Family members, guardians, and authorized representatives System- generated Educational organizations System- generated Employers and businesses System- generated Providers of employment and/or training services System- generated Health, allied health, and rehabilitation organizations System- generated Others System- generated Total System- generated

17 Public Awareness: I&R Individuals Provided with Information or Referred AT Device/Service At Funding Related Disability Topics Total Individuals with disabilities System- generated Family members, guardians, and authorized representatives System- generated Educational organizations System- generated Employers and businesses System- generated Providers of employment and/or training services System- generated Health, allied health, and rehabilitation organizations System- generated Others System- generated Total System- generated

18 Public Awareness: I&R Each individual assisted with information and/or a referral should be counted only once, regardless of the number of contacts made. Coordination and Collaboration Notes

19 Coordination and Collaboration or State Improvement not Previously Addressed Additional Coordination and Collaboration same as in other sections same as in other sections Additional State Improvement Initiatives same as in other sections same as in other sections

20 Expenditures and Other Financial Information In this table, report: a. The amount of AT Act funds expended for each state-level activity. b. The total amount of AT Act funds expended for all state-level activities.* c. The amount of AT Act funds expended for each state leadership activity (not including mandatory transition). d. The amount of AT Act funds expended for transition activities. e. The total amount of AT Act funds expended for all state leadership activities.

21 Expenditures and Other Financial Information Integrated Programs: Enter MD into the rows for which you cannot individually report expenditures. Then report the total amount of funds used for “integrated activities” in the integrated activities row. Funding only should be reported as integrated when the activities are truly integrated. For example, your device demonstration and device loan programs may share both staff and devices, making it difficult to know how much funds are used for each activity.

22 Expenditures and Other Financial Information Activities AT Act Funds Expended Percentage of Total Expenditures Expenditure for stale level activities State FinancingSystem- generated Reutilization$System- generated Device loans$System- generated Device demonstrations$System- generated Integrated activities$System- generated Total expenditures for state-level activities$System- generated Expenditures for state leadership activities Training and technical assistance (other than transition) $System- generated Public awareness$System- generated Coordination and collaboration$System- generated Transition$System- generated Integrated activities$System- generated Total expenditures for state leadership activities$System- generated Total expenditures for all activitiesSystem- generated

23 Additional and Leveraged Funds Enter the sources and amounts of non-AT Act funds that you received during this reporting period Indicate to which activities those funds were allocated. Report each source and amount in the reporting period that it was received, even if not all of the funds were expended. Do not report AFP endowments or matching funds. If funds were used for neither State-level or State Leadership activities report in “Other” and complete narrative section.

24 Additional and Leveraged Funds Name of Funding Source Amount of Funds 1.$ $ $ $ $ $ $ $ (additional rows available as needed $ State FinancingReutilization Demonstration Device LoanTraining Technical Assistance Public Awareness Other

25 Additional and Leveraged Funds 2. (If “other” is selected in Item B.1, Row 1) You indicated that funds from (name of funding source) were used for activities other than the state-level and state leadership activities. a. Describe the “other” activities for which these funds were used. b. How many individuals were served with these additional funds? If you are unable to report this number, enter “MD” for missing data and provide an explanation under “Notes” at the end of this section. (Numeric field) c. What outcomes were accomplished with these additional funds? (Narrative field)