Your Code # is: 

The California Foundation for Independent Living Centers (CFILC) is a group working to improve the lives of people with disabilities. Together with the University of California, San Francisco, the University of Northern Colorado, and California State University, Northridge, we are researching technology used to help people with disabilities in their daily lives. Assistive Technology is any device that a person with a disability uses to live or work more independently. It can be a computer, a walker, or even Velcro on a pen. 

One way to collect a lot of information from a lot of people is to use a survey. Across California people with disabilities will be supported in completing a survey by phone, in writing, in alternate format or in person. This survey will collect information about your Assistive Technology use. 

This survey is considered research. There are rules about protecting people and their rights when doing research. You may choose not to send in the survey or only answer some questions. You can call us at 1-800-390-2699 to ask us about the survey or if you need help filling it out. 

Sending in the survey by mail or over the Internet means you are choosing to answer the survey. No benefit or service will be given or taken away if you answer the survey. We are collecting this information because we believe it will help people understand why Assistive Technology is important. Your responses are welcome. No one will know that you have participated. Patricia Yeager is the Principal Investigator and can be reached by calling our office at 800-390-2699.  Dr. Kenneth Galea’i, Research Support, can be reached at 970-351-1541.

The survey will take between 30 and 40 minutes of your time.  It might take longer if you are using a translator or interviewer. If you would like to take the survey online, please go to www.atnet.org. The survey is also available in alternative formats by calling 800-390-2699. 

To thank you for completing this survey, CFILC would like to send you a check for $20.00.  If you would like to receive this gift you will need to give us your name and address at the end of the survey.  IMPORTANT:  You may take this survey only ONE time, and only ONE check will be issued per person!  You will receive your check from CFILC within 7 days of mailing. Checks will be mailed until monies run out. Once you have completed the survey, place the last page with your name and address in one of the postage-paid envelopes provided.  Then, place the survey form in the other postage-paid envelope and mail both envelopes to CFILC.

For those answering the survey on the Internet:  If you are unable to complete the survey in one session, please click on the “Finish Later” button at the bottom of the page.  You will be given a Record Number and Password - please write these down.  When you return to complete the survey, enter your Record Number and Password into the boxes at the beginning and continue filling out the survey where you left off.

The AT Network website (www.atnet.org) provides information about Assistive Technology and allows individuals to search online for devices and services. People can also receive information about Assistive Technology services and resources by calling the AT Network Information and Referral Service at (800) 390-2699 or through its TDD line at (800) 900-0706.

The Community Research for Assistive Technology project is looking at the use of AT in the lives of people with disabilities. Community disability leaders research AT in four main areas: employment, health, community inclusion and technology for function. For more information about the project, please visit our website at http://www.atnet.org/CR4AT/home.html
or call Myisha Reed, Project Coordinator at: Phone (800) 390-2699, TDD (800) 900-0706 or e-mail: myisha@cfilc.org. You can also send mail to: 1029 J Street, Suite 120, Sacramento, CA 95814. 

NONE OF YOUR RESPONSES WILL IMPACT YOUR BENEFITS. 
1	DO YOU WANT TO PARTICIPATE IN THIS SURVEY?  IF YES PLEASE CONTINUE.
2	IF NO, STOP HERE.  YOU CAN ALSO ASK FOR MORE INFORMATION- PLEASE SEE ABOVE FOR CONTACT INFORMATION.

This survey uses the shortened term “AT” to refer to Assistive Technology.

WHAT IS ASSISTIVE TECHNOLOGY?  (A definition)
Assistive Technology is “any item, piece of equipment, or product, whether acquired commercially, off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of individuals with disabilities.” You might call it a device, aid or tool.

Some of these questions MIGHT NOT apply to you. You may skip questions or answer NA. Please call us if you need any help taking the survey.

1a. What language are you using for this survey? 

 English
 Spanish
 Sign Language 
 Other Language, specify: _______________

1b. How are you filling out this survey? (Check ALL that apply)

 By telephone
 Through an interviewer
 On the Internet
 In writing, by myself

2. Do you use any technical aids or devices (AT)? 

 Yes, Please continue to the next question. 
 No, Please go to question #4.

3a. If you do not use any devices please go to question #4. This question is for people who do use devices. What do you use to help yourself?  If you use more than one device, please identify the ONE device that is MOST IMPORTANT to you. 

 Cane, walker or crutches 			 Hearing aid
 Manual wheelchair 				 Flashing / vibrating alerting 
 Scooter						     device
 Electric wheelchair				 White cane 
 Ventilator 					 Magnifiers
 Oxygen  					 TTY/text pager
 Computer - Off the shelf 			 Relay services 
 Specialized software			     (video/TTY/Internet)
 Specialized hardware 			 Books on tape
 Communication device (such as	 Reacher / Grabber
     an electronic speech output board)	 Adapted vehicle
 Adapted telephone				 Other, please specify
 Adapted eating / cooking utensils	___________________________
 Talking devices (i.e. 			___________________________
     Thermometers, scales)

Questions 3b through 3j are about the device you just identified as the most important to you.  Please skip to Question 4 if you did not name a device.

3b. How old is this device?

  One year old or less
  About 2 years old
  About 3 years old
  About 4 years old
  5 to 10 years old
  More than 10 years old

3c. Where did you learn about the actual AT device?  (Check ALL that apply)

  Health professional			
  California Dept of Rehabilitation			
  Family/Friend						
  Yellow pages  						
  Independent Living Center				
  AT Network						
  Disability Business Technical Assistance Center		
  Internet							
  Catalogue							
  Disability Expo / Conference				
  Television or radio			
  Other, please specify __________________					

3d. How satisfied are you with these issues regarding this device?
 1 is very dissatisfied and 5 is very satisfied.
Very dissatisfied                Very satisfied
Overall experience		 		1  2  3  4  5       
Ability to choose item				1  2  3  4  5  
Help in finding, selecting, and 		1  2  3  4  5  
using the device		 
Cost of device					1  2  3  4  5  
How device works				1  2  3  4  5  
Repairs						1  2  3  4  5  

3e. Which problems make using this device difficult?  
1 is a big problem or not easy at all and 5 is not a problem at all or very easy. 
Big Problem		   Not a Problem
Time delay in getting equipment		1  2  3  4  5  
Additional equipment needed		1  2  3  4  5  
Training not provided				1  2  3  4  5  Equipment not fitting properly		1  2  3  4  5  
Frequent breakdowns				1  2  3  4  5  
Repairs taking too long				1  2  3  4  5     NA

3f. When this device breaks down, how long does it usually take to get it fixed and back to you for use? (Select ONE)

 Less than one week
 1-2 weeks
 3-4 weeks
 Over 4 weeks
 It has never broken down
 Don’t know

3g. When (or if) this device breaks down, do you have a back-up device? (Select ONE)

 Yes
 No 
 I don’t know

3h. How much did this device cost?
$ _______________	 Don’t know

3i. Who paid for this device? (Fill in a number “1” by the primary funding source, fill in a” 2” by a secondary source, if applicable)

__ Private health insurance/HMO
__ Medicare    
__ Medi-Cal 
__ California Department of Rehabilitation   
__ Employer  
__ School system 
__ Regional Center  
__ California Children's Services  
__ VA program 
__ Independent Living Center  
__ Community program  
__ Free/Donated   
__ Family 
__ Self-pay
__ Other. Please specify _________________________

3j. Some people use more than one device to help themselves.  If you use any other devices, please identify the ONE device that is SECOND MOST IMPORTANT to you.  If you do not use any other devices, please skip to Question 4. 

 Cane, walker or crutches 			 Hearing aid
 Manual wheelchair 				 Flashing / vibrating alerting 
 Scooter						     device
 Electric wheelchair				 White cane 
 Ventilator 					 Magnifiers
 Oxygen  					TTY/text pager
 Computer - Off the shelf 			 Relay services 
 Specialized software			     (video/TTY/Internet)
 Specialized hardware 			 Books on tape
 Communication device (such as	 Reacher / Grabber
     an electronic speech output board)	 Adapted vehicle
 Adapted telephone				Other, please specify
 Adapted eating / cooking utensils	___________________________
 Talking devices (i.e. 			___________________________
     Thermometers, scales)

Questions 3k through 3r are about the device you just identified as the second most important to you.  Please skip to Question 4 if you did not name a device.

3k. How old is this device?

  One year old or less
  About 2 years old
  About 3 years old
  About 4 years old
  5 to 10 years old
  More than 10 years old

3l. Where did you hear about or find the actual AT device?  (Check ALL that apply)

  Health professional			
  California Dept of Rehabilitation			
  Family/Friend						
  Yellow pages  						
  Independent Living Center				
  AT Network						
  Disability Business Technical Assistance Center		
  Internet							
  Catalogue							
  Disability Expo / Conference				
  Television or radio			
  Other, please specify __________________					

3m. How satisfied are you with these issues regarding this device?
 1 is very dissatisfied and 5 is very satisfied.
 					    	Very dissatisfied                Very satisfied
Overall experience		 		1  2  3  4  5  
Ability to choose item				1  2  3  4  5  
Help in finding, selecting, and 		1  2  3  4  5  
using the device				 
Cost of device					1  2  3  4  5  
How device works				1  2  3  4  5  
Repairs						1  2  3  4  5  

3n. Which problems make using this device difficult?  
1 is a big problem or not easy at all and 5 is not a problem at all or very easy. 
Big Problem		   Not a Problem
Time delay in getting equipment		1  2  3  4  5  
Additional equipment needed		1  2  3  4  5  
Training not provided				1  2  3  4  5  
Equipment not fitting properly		1  2  3  4  5  
Frequent breakdowns				1  2  3  4  5  
Repairs taking too long				1  2  3  4  5    NA

3o. When this device breaks down, how long does it usually take to get it fixed and back to you for use? (Select ONE)

 Less than one week			1-2 weeks
 3-4 weeks					 Over 4 weeks
 It has never broken down			 Don’t know

3p. When (or if) your equipment breaks down, do you have a back-up device? (Select ONE)

Yes		No			I don’t know

3q. How much did this device cost?
$ _______________  	Don’t know

3r.  Who paid for this device? (Fill in a number “1” by the primary funding source, fill in a” 2” by a secondary source, if applicable)

__ Private health insurance/HMO
__ Medicare    
__ Medi-Cal 
__ California Department of Rehabilitation   
__ Employer  
__ School system 
__ Regional Center  
__ California Children's Services  
__ VA program 
__ Independent Living Center  
__ Community program  
__ Free/Donated   
__ Family 
__ Self-pay
__ Other, please specify _________________________

3s. Do you use any other devices? (Please select ALL that apply)

 Cane, walker or crutches 			 Hearing aid
 Manual wheelchair 				 Flashing / vibrating alerting 
 Scooter						     device
 Electric wheelchair				 White cane 
 Ventilator 					 Magnifiers
 Oxygen  					 TTY/text pager
 Computer - Off the shelf 			 Relay services 
 Specialized software			     (video/TTY/Internet)
 Specialized hardware 			 Books on tape
 Communication device (such as	 Reacher / Grabber
     an electronic speech output board)	 Adapted vehicle
 Adapted telephone				 Other, please specify
 Adapted eating / cooking utensils	___________________________
 Talking devices (i.e. 			___________________________
     Thermometers, scales)

3t. Did funding from other sources (not yourself) affect your AT choices?

Yes		No			I don’t know

3u. Did the price of the device affect your funding choices?

Yes		No			I don’t know

We want to know if your assistive technology (AT) needs have been met. 

4a.  Are there any AT devices and/or aids that you need but do not have? 

 Yes			 No        If no, skip to question 6.

4b.  What aids or devices do you need? (Fill in the blank)
__________________________________________________________
__________________________________________________________

5.  If you need technical aids or devices, but have not been able to get them, please mark all the reasons why: (You may select AS MANY AS NECESSARY)

 Not covered by insurance /Medi-Cal/Medicare
 Too expensive 
 My condition is not serious enough  
 I don’t know where or how to obtain it 
 Devices are not available in my area  
 Some other reason.  Specify:_________________________________

6.   Did you use AT devices in the past but then stop using them?  If no, please skip to question 8  

 Yes   	 	No 	 	Don’t Know   

7. Why did you stop using your AT? 

__________________________________________________________
 NA

8. Name an Assistive Technology (AT) device or equipment (you might not have it now) that could most help you to live independently in the community: 

__________________________________________________
 Don’t know

9. I feel isolated due to my disability: (Select ONE)

 Never.  Please skip to Question 11.
 Rarely.  Please skip to Question 11.
 Sometimes 
 Most of the time 
 Always 
 Don’t know

10. Does using AT help you cope with feeling isolated? (Select ONE)

 Never    Rarely 	 Sometimes 	 Most of the time  	Always 
 Not applicable to me  (IF you do not use AT you select this answer)

You might not use AT now, but if you think it would help in activities you do, please answer this question. If not applicable please skip to #13 

11. For which activities in the home do you need AT? (Check ALL that apply to you): 

 Cooking/eating  		 Cleaning
 Parenting  			 Watching TV 			 
 Alerting/Signaling		 Communicating		 
 Getting around		 Writing				 
 Computer Use		 Personal care - includes dressing,
 Reading 				toileting, bathing, brushing teeth, etc.
 Paying bills		
 Other- please describe 	     
_____________________	

12. For which activities in the community do you need assistive technology (AT)? (Check ALL that apply to you)

 Errands				 Shopping 				 
 Family activities		 Social/Community Activities	 
 Health appointments  	 Taking classes  				 
 Volunteering  			 Transportation			 
 Sports and Recreation 	 Communicating with others
 Reading 			 Employment (any type-full or part-time)	
Other- please describe     
_____________________

CFILC would like to know what changes would improve the system that provides, funds and repairs devices and equipment (AT). Even if you do not use devices or AT right now, you still may have ideas. 

13.  If changes could be made to the AT system, what would you like to see happen? (Please check ALL that apply)

 Insurance system changed    		 Case managers available
 Try-out facilities for AT 			 Persons with disabilities 
 More affordable AT                                  included as decision makers
 More universal design     			     in funding process
 Expand definition of AT  			 Devices easier to get  
 Better system for repairs			 Persons with disabilities 
 National standardization for all 		      involved in the design process
     agencies 					 Training on use of equipment
 Collaboration amongst agencies	 Don’t know
 Other ____________________

14a. Do you use a TTY/TDD?  (Select only ONE)  

 Yes   	 No 	 Don’t Know   

If you answered NO or DON’T KNOW please go to question #16.  If you answered YES please answer #14b. 

14b. Do you use a relay service to communicate with people or businesses who don’t have a TTY/TDD?

 Yes		 No		Sometimes 	 I don’t know

15. When using your TTY/TDD are you able to reach people (with or without a relay service) at the following places?   (Select ONE answer for each area)

15a. Your health professional’s office:	     
 Yes   Sometimes   No NA 
15b.Your school or your children’s school: 
 Yes   Sometimes   No NA
15c. Businesses, restaurants or stores:     
 Yes   Sometimes   No NA
15d. Community services, such as seniors center:  
 Yes   Sometimes   No NA
15e. Government agencies, such as SSI:  
 Yes   Sometimes   No NA

PLEASE REMEMBER: NO BENEFITS OR SERVICES ARE AFFECTED BY YOUR ANSWERS. WE WOULD LIKE TO KNOW HOW ASSISTIVE TECHNOLOGY IS USED FOR YOUR HEALTH.

Health
16. Is your most important healthcare setting accessible to you? (Select ONE)

 Not at all   Mostly not   Somewhat   Mostly   Totally
 Don’t know

17. Does your health professional have a weight scale that weighs you properly? (Select only ONE)

 Yes     No	   Don’t Know 

18a. Which of the following do you use while at the health professional’s office? Please check ALL that apply:

 X-ray  						 Ramps
 Scale  						 Braille/audio formats for 
 Mammography  				     information
 Exam table  					 Non-English
 Sign Language Interpreter  		     brochures/interpreters
 Lifts to get on equipment or table 	 Lab tests – urine/blood testing,
     from wheelchair   				     blood pressure
 TTY’s  						 None of the above
 Electric doors  				 Don’t know
 Hand/grab rails  				 Other ____________________
 Ultrasound machines 

18b. Which of the following are you prevented from using because it isn’t available or isn’t accessible? Please check ALL that apply:

 X-ray  						 Ramps
 Scale  						 Braille/audio formats for 
 Mammography  				     information
 Exam table  					 Non-English
 Sign Language Interpreter  		     brochures/interpreters
 Lifts to get on equipment or table 	 Lab tests – urine/blood testing,
     from wheelchair   				     blood pressure
 TTY’s  						 None of the above
 Electric doors  				 Don’t know
 Hand/grab rails  				 Other ____________________
 Ultrasound machines 

19. In your opinion, how knowledgeable is your primary health professional about the range of Assistive Technologies? (Select ONE)

 Poor    Fair   Adequate  Excellent   Don’t know

IN THIS NEXT SECTION WE WANT TO KNOW ABOUT USING ASSISTIVE TECHNOLOGY FOR EMPLOYMENT.  SOME OF THESE QUESTIONS MAY NOT APPLY TO YOU.
Employment
20a. Please tell us about your employment situation. (Select all that apply)

 I work full time
 I work part time
 I am self-employed
 I am working, but not as many hours as I would like
 I am not currently working

20b Answer this question only if you are NOT currently working. (Select all that apply)

 I would prefer to work
 I feel I am able to work
 I am looking for work
 I am volunteering
 I am in school, training for a job
 None of the above

21. What assistive technology device or equipment would help you the most to get or keep a job, full or part time?  _________________________________________________________
_________________________________________________________
_________________________________________________________
 Don’t know 	  Not applicable 

22. How well has AT helped you in searching for a job? (Select ONE) 

 Not at all   Very little   Average   A lot   Immensely 
 Not applicable 

 If you are NOT working now, please go to question #29.

23. Please check ALL devices or services you use to perform work duties:

 Magnifier  					Telephone headset
 Wheelchair  					 Mouth stick
 Wrist splints 					 Support for personal functions:
 Service animal  				     eating, bathroom
 Computer software to read the 		 Personal assistant
     screen in synthesized voice		 Adapted mouse 
 Computer hardware to output 		 Adapted computer screen, i.e. 
     in Braille 					     larger screen or flat screen
 Voice activated software			 Adapted keyboard
 Hearing aid/amplification device 	 Support for mental limitations -  
 TTY/Pager/text communicator 		     job coaching
 Automatic doors 				 Ergonomic table / chair
 Ramps 						 Interpreters
 Tape recorder 				 Readers
 Amplified telephone 			 Other ____________________

24. Have you ever requested an AT device as an accommodation from your employer?  

 Yes      No 		 Don’t Know		 Not Applicable to me
If yes, answer 25, If no, go to question 26

25. What was the outcome when you requested a device from your employer? (Select as MANY as applicable)

 I got the device   			 
 My requested was denied	     
 Referred to California Department of Rehabilitation
 Referred to someone for an evaluation
 Employer paid for all of it		
 I was asked to pay part
 Employer said I had to buy it myself
 Other _________________

26. How did you acquire the AT devices you use at work? (Select up to THREE)

 Employer  			 Self-pay
 Health Insurance  		 Not applicable 
 Donated 			 Other _______________________
 California Department of Rehabilitation 

27. How well have AT devices helped you at work? (Select ONE)

 Not at all   Very little   Average   A lot   Immensely
 Not applicable to me 

Please answer this question if someone else paid for your device(s).

28. If you changed jobs tomorrow, could you take the devices paid for by your employer, Department of Rehabilitation, or someone else from your current job to another job? (Select ONE) 

 Yes 	   No 	 Not sure	 Not applicable

This question is for anyone to answer.

29. If you had to choose what MOST limits you from working to your fullest ability, it would be: (Please rank the top 3 reasons with 1 being the most limiting and 3 being the least limiting)

___My disability   
___Lack of jobs
___Lack of education
___Problems with self-esteem  
___Lack of assistive technology
___Attitudes of employers/the public
___Access in general to get in and around places  
___Poverty, lack of financial stability  
___Fear 
___Potential loss of benefits / health coverage  
___Communication Barriers
___Lack of transportation
___I do not feel limited
___Other_______________

30. Did you know that employers can qualify for incentives to help pay for AT needed at work? (Select ONE) 

 Yes 	  No 

31. Please answer this question if you use AT when working or volunteering; if not, please go to the next question. In the last month, the use of AT in my work/volunteering has resulted in (Mark ALL that apply)

a. Improved productivity   	 Yes 	 Somewhat  	 No
b. More paid work hours	 Yes 	 Somewhat  	 No
c. Better attendance 		 Yes 	 Somewhat  	 No
d. Improved self-esteem 	 Yes 	 Somewhat  	 No

If you do not have devices now, but might in the future please continue by answering the following questions. Current users of AT devices should also answer.

32. Would you be willing to pay a share of the cost if it would speed up the process of getting the AT you need?

 Yes, if I had the money 	  No 	  Don’t know

33. How much would you be willing to spend if you had to pay for AT out of your own pocket? (Select only ONE range please.)

 $1 - $99    			 $1600 - $2000
 $100-  $499    		 More than $2000
 $500 - $999     		 Not applicable
 $1000 - $1500  		 Don’t know

TO HELP US UNDERSTAND THE ANSWERS TO THIS SURVEY WE NEED TO KNOW INFORMATION ABOUT PEOPLE WHO FILLED OUT THE SURVEY.  WE NEED SOME INFORMATION ABOUT YOUR PERSONAL SITUATION. 

34. Select ALL that apply:					

 I am a parent of children under 18
 I am providing care for my own parents 
 I am providing care for an adult with disabilities over 18 
 A family member provides attendant care for me
 Paid caregivers (attendants and others) provide services to me 
 I provide my own care 

35.  Select the ONE answer that best describes your living situation this month:

 I live independently by myself 
 I live with at least one other person (roommate, spouse, child) 
 I live with family  (parents or adult relatives)
 I live with a live-in caretaker
 I am homeless 
 I live in a group home or supervised living environment 
 I live in an institution or nursing home  
 None of the above 
You may write in an answer that describes your situation best:
_________________________________________________

36. What is your Zip Code? _____________ 

37. Select the ONE answer that best fits you:  

 Male    Female   Transgender   Intersexed   

38. Race & Ethnicity: (Select as many as apply)

 White  
 Hawaiian/Pacific Islander 
 Black/African American  
 Asian 
 American Indian/Alaska Native 
 Hispanic/Latino/a
 Other, please specify ____________________ 
 Decline to State  

39. Select ONE category for your education level: 

 1-8 years
 9-12 years without diploma
 High school diploma or GED
 Some college but no bachelor’s degree
 College graduate
 Graduate or professional degree

40. Please estimate annual income for your entire household in 2004, by selecting ONE category:

 Less than $5,000 			 	 $35,000-$49,999	
 $5,000-$9,999				  $50,000-$69,999
 $10,000-$14,999   				  $70,000-$89,999       
 $15,000-$19,999				  $90,000 or more
 $20,000-$24,999   				  Decline to state		
 $25,000-$34,999				  Don’t know 

41. What is the main source of your income? (Select up to TWO)

 Employment   
 Self-employment 
 Pension/Retirement   
 Federal government funding (SSI, SSDI TANF) 
 Student Financial Aid  
 Personal/family wealth 
 Inheritance 
 Child support  
 Insurance settlement for injury
 Workers Compensation
 Don’t know
 General Assistance				
 Other _________________

42. What best describes your major activities in 2004? (Check up to TWO areas)

 In school 
 Working
 Volunteering
 Advocacy
 Parenting
 Keeping house
 Developing independence
 Caring for myself
 Caring for others
 Hobbies and leisure activities

43.  This question is for people that no longer work, but did in the past. If you used to work, but don’t any longer, is it because of: (Select ONE) 

 I acquired a disability or it got      
        worse
  Normal retirement 
  Early retirement  
  My disability benefits prevent me from working 
  None of the above

44. How old are you today?

 18-24    25-44    45-54   55-64   65-74   75-84   85+  

45. At what age did you first start having any difficulty or activity limitation?  

  Since birth   Under 18   18-44   45-54   55-64   65-74  
 75-84  	        85+

46. Which of the following statements apply to you (Check all that apply)

 I am blind
 I have low vision
 I am Deaf
 I am hard of hearing
 I don’t speak
 People have trouble understanding me when I speak
 I can’t get around without help or equipment
 I have trouble walking or am limited in mobility
 I have mental retardation
 I have a developmental disability
 I have a learning disability
 I have a mental health or psychiatric disability
 I have some other type of disability Specify: ______________________

IMPORTANT: From Page #1 please enter your survey code here ______________________.

The Community Research for Assistive Technology project would like to thank you for taking our survey. By filling out this survey, you are helping us get one step closer to understanding the gap in Assistive Technology for persons with disabilities. 

A website (www.atnet.org) has also been developed to provide information about the AT Network. The AT Network website also provides articles on Assistive Technology and allows individuals to search online for Assistive Technology and services. Individuals can also receive information concerning Assistive Technology services and resources by calling the AT Network's Information and Referral Service at (800) 390-2699 or through its TDD line at (800) 900-0706.  The AT Network can also be reached by fax at (916) 325-1699 and e-mail at info@atnet.org.

Please fill out this form to receive your $20.00 gift.  Two self-addressed postage paid envelopes have been provided. Mail the completed form in the first envelope. In the second envelope, mail your completed survey. This helps us to maintain your confidentiality. If no envelopes are attached, please send to: 		
CFILC/AT Survey
1029 J Street, Suite 120 
Sacramento, CA  95814 

If you would like to receive the $20.00 gift, please provide your name and mailing address below:

Name: __________________________________________________

Street Address or P.O. Box: _________________________________

City: ____________________________________________________
State: ___________  Zip Code: ____________________

IMPORTANT REMINDER:  You may take this survey only ONE time, and only ONE check will be issued per person!   You will receive your check from CFILC within 7 days of mailing. Checks will be mailed until monies run out.