1. 0 Device Reutilization: General Device reutilization includes:  device exchange  program serves as intermediary  program does NOT serve as intermediary  device recycle/refurbish  device repair  open-ended device loans

2. 1 Device Reutilization: Exchange First 2 years of data collection. If you have a device exchange in which you do not serve as the intermediary, you may: 1)Choose not to collect and report data on your exchange activity; 2)Collect information from the current owner of the device; 3)Collect information from the recipient of the device; or 4)Collect information from a combination of the recipient and current owner.

3. 2 Device Reutilization: Exchange You must establish your method of data collection up front. You must use a consistent method. You can change methods from the first year of the pilot to the second. You will indicate which method of data collection you are using. You will provide a narrative explanation of how you are collecting data, any challenges experienced in using this method, and plans for overcoming those challenges.

4. 3 Device Reutilization: Exchange You still are responsible for collecting all data. Report data only when you have attempted to obtain the performance measure data. Nonrespondents will not count in the performance measure. At the conclusion of the pilot, a threshold nonresponse rate will be established.

5. 4 1. Did your statewide AT program conduct device reutilization activities* during the reporting period? 1. Did your statewide AT program conduct device reutilization activities* during the reporting period? 2. Did you operate a device exchange program* in which you did not serve as the intermediary? 2. Did you operate a device exchange program* in which you did not serve as the intermediary? Drop-down box: (1) yes; (2) no 3. (If “Yes” to Item 2) Are you piloting a data collection method for this device exchange program?* 3. (If “Yes” to Item 2) Are you piloting a data collection method for this device exchange program?* Drop-down box: (1) yes; (2) no, data on this activity are not being reported 4. (If “Yes” to Item 3) Please identify your data collection method. 4. (If “Yes” to Item 3) Please identify your data collection method. Drop-down box: (1) collecting data from seller only; (2) collecting data from buyer only; (3) collecting data from both seller and buyer Device Reutilization

6. 5 Insert table “number of reutilized devices” from pg 18 ActivityNumber of Individuals Device Exchange Recycling/refurbishing/repair Open-ended loans Subtotal of recycling/refurbishment/repair and open-ended loans System- generated Total of all device reutilizationSystem- generated

7. 6 Insert device exchange activities table from top of page 19 Type of AT Device Are devices in this category included in your listing? Number Total Estimated Current Purchase Price Total Amount for Which Devices Were Sold Savings to Consumers Speech communicationY/N System- generated VisionY/NSystem- generated HearingY/NSystem- generated Computers and relatedY/NSystem- generated Daily livingY/NSystem- generated Learning, cognition, and developmental Y/NSystem- generated Environmental adaptationsY/NSystem- generated Mobility, seating and positioning Y/NSystem- generated Vehicle modification and transportation Y/NSystem- generated Recreation, sports, and leisure Y/NSystem- generated Other (specify)System- generated Total System- generated

8. 7 Insert device recycling activities table from top of page 20 Type of AT Device Are devices in this category included in your listing? Number Recycled/ Refurbished /Repaired Total Estimated Current Purchase Price Total Amount for Which Devices Were Sold Savings to Consumers Speech communicationY/N System- generated VisionY/NSystem- generated HearingY/NSystem- generated Computers and relatedY/NSystem- generated Daily livingY/NSystem- generated Learning, cognition, and developmental Y/NSystem- generated Environmental adaptationsY/NSystem- generated Mobility, seating and positioning Y/NSystem- generated Vehicle modification and transportation Y/NSystem- generated Recreation, sports, and leisure Y/NSystem- generated Other (specify)System- generated Total System- generated

9. 8 Insert open-ended loan activities table from top of page 21 Type of AT Device Are devices in this category included in your listing? Number Loaned Total Estimated Current Purchase Price Cost to Consumer for the Loan Savings to Consumers Speech communicationY/N System- generated VisionY/NSystem- generated HearingY/NSystem- generated Computers and relatedY/NSystem- generated Daily livingY/NSystem- generated Learning, cognition, and developmental Y/NSystem- generated Environmental adaptationsY/NSystem- generated Mobility, seating and positioning Y/NSystem- generated Vehicle modification and transportation Y/NSystem- generated Recreation, sports, and leisure Y/NSystem- generated Other (specify)System- generated Total System- generated

10. 9 Device Reutilization Coordination and Collaboration Anecdote Performance Measure Customer Satisfaction Notes (2) General Notes General Notes Pilot Program Notes Pilot Program Notes

11. 10 Device Loans: General By definition these are short-term loans. {Open-ended loans are reutilization} Loans can be for: decisionmaking decisionmaking “filling in the gap” “filling in the gap” short-term accommodation short-term accommodation self-education by a consumer or intermediary self-education by a consumer or intermediary training training Only loans for the purpose of decision-making should be included in the performance measures.

12. 11 Device Loans: Number of Borrowers Same introductory questions as previous sections. If your program considers a loan to an “intermediary” on behalf of five “end users” to be a single loan, count only the intermediary as the borrower. If your program considers this to be five loans, count all five students as borrowers. [You must be able to get this data!] Performance measures must be consistent with above! If the same individual or entity borrows devices on more than one occasion during the reporting period, count each occasion as a separate loan.

13. 12 Insert table from page 27 Insert table from page 27 Type of Individual or EntityNumber of Device Borrowers Individuals with disabilities Family members, guardians, and authorized representatives Educational organizations Employers and businesses Providers of employment and/or training services Health, allied health, and rehabilitation organizations Others TotalSystem- generated

14. 13 Device Loans: Number of Loans Number of short-term device loans made during the reporting period: (Numeric field) If the same individual or entity borrows devices on more than one occasion during the reporting period, count each occasion as a separate loan. If you extend the period of a short-term device loan, count that as a separate loan only if: the extension is for a different purpose than the original loan; or (2) the borrower is an “intermediary” borrowing on behalf of others and the intermediary is requesting an extension to accommodate a second “end user.” (2) the borrower is an “intermediary” borrowing on behalf of others and the intermediary is requesting an extension to accommodate a second “end user.” Be consistent with rules for number of borrowers.

15. 14 Device Loans: Length D. Length of Short-Term Device Loans 1. What is the usual length of a short-term device loan, as established by your statewide AT program’s policies? 1. What is the usual length of a short-term device loan, as established by your statewide AT program’s policies? If your program does not have an established policy, enter the average length of short-term device loans.* Please report the length in calendar days. Usual length of short-term device loan,* in days: (Numeric field)

16. 15 Insert “types of device loaned” table from top of page 28 Type of AT Device Are devices in this category included in your listing? Number Loaned Speech communicationY/N VisionY/N HearingY/N Computers and relatedY/N Daily livingY/N Learning, cognition, and developmentalY/N Environmental adaptationsY/N Mobility, seating and positioningY/N Vehicle modification and transportationY/N Recreation, sports, and leisureY/N Other (specify) TotalSystem- generated

17. 16 Insert primary purpose of device loan table from middle of page 28. Primary Purpose of Short-Term Device LoanNumber A. Assist in decision making (device trial or evaluation) B. Serve as loaner during device repair or while waiting for funding C. Provide an accommodation on a short-term basis D. Other TotalSystem- generated

18. 17 Device Loans Coordination and Collaboration Anecdote Performance Measure Customer Satisfaction Notes

19. 18 Device Demonstrations: General Device demonstrations enable an individual to make an informed choice. They are not:  Training activities at which devices are demonstrated.  Public awareness activities at which devices are demonstrated.

20. 19 Device Demonstrations: General There are 2 types of device demonstrations: 1. Direct The consumer can physically interact with the device The consumer can physically interact with the device 2. Indirect The consumer does not interact with the device. The consumer does not interact with the device.

21. 20 Device Demonstrations: Number of Demonstrations A. Number of Demonstration Sessions and Devices Demonstrated; Number of People Making a Decision 1. In the table below, enter 1. In the table below, enter a. The total number of direct and indirect demonstration sessions you conducted during the reporting period [Column (a)]. a. The total number of direct and indirect demonstration sessions you conducted during the reporting period [Column (a)]. b. The total number of devices demonstrated [Column (b)]. b. The total number of devices demonstrated [Column (b)]. c. The total number of decisionmakers (or for individuals for whom a decision is being made). This category includes consumers and individuals representing an agency or organization c. The total number of decisionmakers (or for individuals for whom a decision is being made). This category includes consumers and individuals representing an agency or organization

22. 21 Insert table from bottom of page 33 Type of Demonstration (a) Number of Demonstration Sessions (b) Number of Devices Demonstrated (c) Number of Individuals Participating in Demonstration (d) Number of People Who Are Making A Decision (or for Whom a Decision is Being Made) DirectY/N IndirectY/N Total System- generated

23. 22 Device Demonstration: Types of Participants C. Types of Participants 1. In the table below, enter the number of individuals who participated in direct and indirect demonstration sessions, by type of participant. Include all individuals participating in demonstrations, not just those who are making a decision (or for whom a decision is being made). 1. In the table below, enter the number of individuals who participated in direct and indirect demonstration sessions, by type of participant. Include all individuals participating in demonstrations, not just those who are making a decision (or for whom a decision is being made). If an individual participated in more than one demonstration session, count him or her only once.

24. 23 Insert table C.1 from page 34 Type of ParticipantDirect DemonstrationsIndirect Demonstrations Individuals with disabilities Family members, guardians, and authorized representatives Educational organizations Employers and businesses Providers of employment and/or training services Health, allied health, and rehabilitation organizations Others TotalSystem- generated

25. 24 Device Demonstrations: Referrals For participants attempting to make a decision about an AT device or service, enter the number of referrals made to each type of entity. Since an individual may receive more than one referral, the number of referrals may exceed the number of participants. Do not include referrals to other components of your statewide AT program. Do not include I&R referrals here. Do not include referrals to your own program. A referral includes: specific information about where a customer may obtain additional information or services related to AT and how to contact that source directly.

26. 25 Insert table C.2 from page 34 here Type of EntityNumber of Referrals Funding source (non-At program) Service provider Vendor Repair service OthersSystem- generated

27. 26 Insert table from top of page 35 here Type of AT Device/ServiceDirect DemonstrationsIndirect Demonstrations Speech communication Vision Hearing Computers and related Daily living Learning, cognition, and developmental Environmental adaptations Mobility, seating and positioning Vehicle modification and transportation Recreation, sports, and leisure Other (specify) TotalSystem- generated

28. 27 Device Demonstrations Coordination and Collaboration Anecdote Performance Measure Customer Satisfaction Notes