Exit Survey

Contact Information

First Name *

Last Name *

Email *

County

Address

City

State/Province

Zip/Postal

Data Collection Survey

Please answer the following questions about the services you received from the Illinois Assistive Technology Program. We need this information to provide high-quality services and to meet the requirements for receiving federal funding.

Which of the following best reflects your level of satisfaction with the services you received?

Highly satisfied

Satisfied

Satisfied somewhat

Not at all satisfied

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

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

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

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.

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.

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Data Collection Survey

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