Client Satisfaction Questionnaire

Contact Information





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?
The primary purpose for which I need (or the person I represent needs) an AT device or service is related to:
Why did you chose to obtain an AT device/service from our program?

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.