MN Resource Libraries AT Loan Program Trial Data & Information
In order to justify the expenditure of WIOA funds for high cost assistive technology, please complete this survey after borrowing AT equipment for students who are age 14 and above. Please do NOT include any student specific identifiable information other than age of student in this survey. No student names are necessary.
Date of request:
Name of TBVI or COMS:
Age of student for whom equipment is being borrowed:
Name of AT device trialed:
Length of time the device was trialed with the student in the intended environment/s?
Was a device purchased for the student as a result of the AT Loan Program?
Never submit passwords through Google Forms.
This form was created inside of MN State Academies.