1. 0 Performance Measures: General Two survey instruments are provided: one for the “access” measure, and one for the “acquisition” measure. Two survey instruments are provided: one for the “access” measure, and one for the “acquisition” measure. You must use these instruments You must use these instruments However, you can incorporate the survey into your reporting system, if you don’t change the language. However, you can incorporate the survey into your reporting system, if you don’t change the language.

2. 1 Performance Measures: General Who to Survey All consumers served by state financing or device reutilization that obtain a device.All consumers served by state financing or device reutilization that obtain a device. Device loan or demonstration customers who were there for decision-making purposes.Device loan or demonstration customers who were there for decision-making purposes. When loans or demonstrations are provided to multiple representatives of the same organization, you designate a single individual to respond. When loans or demonstrations are provided to multiple representatives of the same organization, you designate a single individual to respond. When one individual acts on behalf of several others the survey can be administered: When one individual acts on behalf of several others the survey can be administered: Once for each end user, or; Once for each end user, or; Once to the person representing end users. Once to the person representing end users.

3. 2 Performance Measures: General How and When to Survey You may administer the survey the way it best meets your needs. You may administer the survey the way it best meets your needs. Administer the appropriate section of the survey at the appropriate time. Administer the appropriate section of the survey at the appropriate time. Device loans = complete when the device is returned. Device loans = complete when the device is returned. Demonstrations = complete when the demonstration is concluded. Demonstrations = complete when the demonstration is concluded. When service is complete in one reporting period but follow-up not complete until the next reporting period – report the service and follow-up both as taking place in the “follow-up” reporting period. When service is complete in one reporting period but follow-up not complete until the next reporting period – report the service and follow-up both as taking place in the “follow-up” reporting period.

4. 3 Performance Measures: Non-responders Obtain as high a response rate as possible. Obtain as high a response rate as possible. Report only true non-responders: those individuals with whom you attempted a follow- up. Report only true non-responders: those individuals with whom you attempted a follow- up. Do not include an individual as either served or as a non-responder when you did not even make an attempt to get information. Do not include an individual as either served or as a non-responder when you did not even make an attempt to get information. Specific instructions for counting non- responders are included in the relevant section. Specific instructions for counting non- responders are included in the relevant section.

5. 4 Performance Measures: Acquisition TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________  ID (optional) ____________  Services provided:  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 OR OR Device recycling—received an AT device through a device recycling program  Date service delivery was completed: __________  Date this form was received: ____________________

6. 5 Performance Measures: Acquisition 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: 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 Education—participating in any type of educational program Community living—carrying out daily activities, participating in community activities, using community services, or living independently 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 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

7. 6 Performance Measures: Acquisition 2. Why did you chose to obtain an AT device/service from our program? 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. _____ 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

8. 7 Performance Measures: Acquisition - State Financing Response Primary Purpose for Which AT is Needed Total EducationEmployment Community Living 1. Could only afford the AT through the statewide AT program (n,d) System- generated 2. AT was only available through the statewide AT program (n,d) System- generated 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) System- generated 4. Subtotal System- generated 5. None of the above (d) System- generated 6. Subtotal System- generated 7. Nonrespondent (d) System- generated 8. Total System- generated 9. Performance on this measure System- generated

9. 8 State Financing: Table with Sample Data Response Primary Purpose for Which AT is Needed Total EducationEmployment Community Living 1. Could only afford the AT through the statewide AT program (n,d) 30 System- generated 2. AT was only available through the statewide AT program (n,d) 30 System- generated 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) 20 System- generated 4. Subtotal80 System- generated 5. None of the above (d)10 System- generated 6. Subtotal90 System- generated 7. Nonrespondent (d)10 System- generated 8. Total100 System- generated 9. Performance on this measure80% System- generated (Includes sample data for a grantee with 100 customers identifying education as primary purpose for which AT is needed and a response rate of 90 percent)

10. 9 Performance Measures: Acquisition - Recycling Response Primary Purpose for Which AT is Needed Total EducationEmployment Community Living 1. Could only afford the AT through the statewide AT program (n,d) System- generated 2. AT was only available through the statewide AT program (n,d) System- generated 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) System- generated 4. Subtotal System- generated 5. None of the above (d) System- generated 6. Subtotal System- generated 7. Nonrespondent (d) System- generated 8. Total System- generated 9. Performance on this measure System- generated

11. 10 Recycling: Table with Sample Data Response Primary Purpose for Which AT is Needed Total EducationEmployment Community Living 1. Could only afford the AT through the statewide AT program (n,d) 30 System- generated 2. AT was only available through the statewide AT program (n,d) 30 System- generated 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) 20 System- generated 4. Subtotal80 System- generated 5. None of the above (d)10 System- generated 6. Subtotal90 System- generated 7. Nonrespondent (d)10 System- generated 8. Total100 System- generated 9. Performance on this measure80% System- generated (Includes sample data for a grantee with 100 customers identifying education as primary purpose for which AT is needed and a response rate of 90 percent)

12. 11 Performance Measures: Acquisition - Exchange Response Primary Purpose for Which AT is Needed Total EducationEmployment Community Living 1. Could only afford the AT through the statewide AT program (n,d) System- generated 2. AT was only available through the statewide AT program (n,d) System- generated 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) System- generated 4. Subtotal System- generated 5. None of the above (d) System- generated 6. Subtotal System- generated 7. Nonrespondent ((d) if AT program is intermediary) System- generated 8. Total System- generated

13. 12 Exchange: Table with Sample Data Response Primary Purpose for Which AT is Needed Total EducationEmployment Community Living 1. Could only afford the AT through the statewide AT program (n,d) 20 System- generated 2. AT was only available through the statewide AT program (n,d) 10 System- generated 3. AT was available through other programs, but the system was too complex or the wait time was too long (n,d) 10 System- generated 4. Subtotal40 System- generated 5. None of the above (d)10 System- generated 6. Subtotal50 System- generated 7. Nonrespondent ((d) if AT program is intermediary)50 System- generated 8. Total100 System- generated (Includes sample data for a grantee with 100 customers identifying education as primary purpose for which AT is needed and a response rate of 50 percent)

14. 13 Performance Measures: Access TO BE COMPLETED BY PROGRAM STAFF  ID (optional) ____________  ID (optional) ____________  Services provided:  Services provided: Device demonstration Device demonstration OR OR Device loan Device loan  Date service delivery was completed: __________  Date service delivery was completed: __________  Date this form was received: ____________________  Date this form was received: ____________________

15. 14 Performance Measures: Access 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. 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

16. 15 Performance Measures: Access 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? 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 meet my needs (or the needs of someone I represent). _____ Decided that an AT device or service will not meet my needs (or the needs of someone I represent). _____ Decided that an AT device or service will not meet my needs (or the needs of someone I represent). _____ Have not made a decision. _____ Have not made a decision.

17. 16 Performance Measures: Access - Device Loan Primary Purpose for Which AT is Needed ResponseEducation Employment Community Living IT/Telecomm unications Total 1. Decided that an AT device/service will meet needs (n,d) System- generated 2. Decided that an AT device/service will not meet needs (n,d) System- generated 3. Subtotal System- generated 4. Have not made a decision (d) System- generated 5. Subtotal System- generated 6. Nonrespondent (d, if > 35%) System- generated 7. Total System- generated

18. 17 Device Loan: Table with Sample Data Primary Purpose for Which AT is Needed ResponseEducation Employment Community Living IT/Telecomm -unications Total 1. Decided that an AT device/service will meet needs (n,d) 30 System- generated 2. Decided that an AT device/service will not meet needs (n,d) 15 System- generated 3. Subtotal45 System- generated 4. Have not made a decision (d)10 System- generated 5. Subtotal55 System- generated 6. Nonrespondent (d, if > 35%)45 System- generated 7. Total100 System- generated (Includes sample data for a grantee with 100 customers identifying education as primary purpose for which AT is needed and a response rate of 55 percent [10 percent of nonrespondents included in denominator])

19. 18 Performance Measures: Access - Demonstration Primary Purpose for Which AT is Needed ResponseEducation Employment Community Living IT/Telecomm unications Total 1. Decided that an AT device/service will meet needs (n,d) System- generated 2. Decided that an AT device/service will not meet needs (n,d) System- generated 3. Subtotal System- generated 4. Have not made a decision (d) System- generated 5. Subtotal System- generated 6. Nonrespondent (d) System- generated 7. Total System- generated 8. Performance on this measure System- generated

20. 19 Demonstration: Table with Sample Data Primary Purpose for Which AT is Needed ResponseEducation Employment Community Living IT/Telecomm unications Total 1. Decided that an AT device/service will meet needs (n,d) 50 System- generated 2. Decided that an AT device/service will not meet needs (n,d) 30 System- generated 3. Subtotal80 System- generated 4. Have not made a decision (d)10 System- generated 5. Subtotal90 System- generated 6. Nonrespondent (d)10 System- generated 7. Total100 System- generated 8. Performance on this measure80% System- generated (Includes sample data for a grantee with 100 customers identifying education as primary purpose for which AT is needed and a response rate of 90 percent)

21. 20 Customer Satisfaction Collected only on state-level activities – but collected separately for each activity. Collected only on state-level activities – but collected separately for each activity. A survey instruments is provided. A survey instruments is provided. You must use this instrument... You must use this instrument... However, you can incorporate the survey into your other surveys, if you don’t change the language. However, you can incorporate the survey into your other surveys, if you don’t change the language.

22. 21 Customer Satisfaction Who to Survey All consumers served by state-level activities. All consumers served by state-level activities. When one individual acts on behalf of several others the survey is just to the representative, not all end users. When one individual acts on behalf of several others the survey is just to the representative, not all end users. Nonrespondents will not be included in the denominator. Nonrespondents will not be included in the denominator. However, you will indicate the number of customers you surveyed and the number who responded so that a response rate can be calculated. However, you will indicate the number of customers you surveyed and the number who responded so that a response rate can be calculated.

23. 22 Customer Satisfaction How and When to Survey You may administer the survey the way it best meets your needs. You may administer the survey the way it best meets your needs. Administer at the appropriate time. Administer at the appropriate time. When service is complete in one reporting period but follow-up not complete until the next reporting period – report the service and follow-up both as taking place in the “follow-up” reporting period. When service is complete in one reporting period but follow-up not complete until the next reporting period – report the service and follow-up both as taking place in the “follow-up” reporting period.

24. 23 Customer Satisfaction TO BE COMPLETED BY AT PROGRAM STAFF  ID (optional) ____________  ID (optional) ____________  Services provided:  Services provided: Device demonstration Device demonstration Device loan Device loan “State financing” services—including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and services at reduced cost or free, or other related services “State financing” services—including financial loan, assistance in accessing funds for AT devices/services, assistance in obtaining AT devices and services at reduced cost or free, or other related services Device reutilization— received an AT device through a device exchange or recycling program Device reutilization— received an AT device through a device exchange or recycling program  Date service delivery was completed: __________  Date service delivery was completed: __________  Date this form was received: ____________________  Date this form was received: ____________________

25. 24 Customer Satisfaction Which of the following best reflects your level of satisfaction with the services you received? 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

26. 25 Customer Satisfaction Customer Rating of ServicesNumber of Customers Highly satisfied Satisfied Satisfied somewhat Not satisfied Nonrespondent TotalSystem- generated Response RateSystem- generated