Perhaps I don't understand the question... With level three, one is attempting to assess whether or not what was learned is being applied (aka "Are they using it?")
It's my experience that there is no such thing as a level three evaluation that applies from one person's organization to another, nor from one course to another. Each time you assess this, there are too many factors that are unique to your organization, the course, the learners, etc. for someone else's eval to apply to you/your org.
Exactly as what Fanatic said, there will be no one standard Level 3 that will apply cross-functionally and cross-organizationally. This will be based on the need of your program....what are your objectives for the program? What are you trying to accomplish on-the-job? This will help to dictate what types of data collection you'll need to do at the Level 3 of eval.
I highly recommend the ASTD's Certificate Program in Measuring and Evaluating Learning, if you have not already taken it. It will really help out with the definition of each of the levels and provide some groundwork for what to do and when.
Per your request I have sent a Level 3 evaluation sample...but with a twist.
In my web-based evals I ask the participants about the degree to which their new skills and knowledge are encouraged and supported in the workplace.
Focusing L3 on managers-supervisors...et al completely misses the single most critical aspect of any developmental initiative....what the organization does for the new learner after the learning event. Checking out post training support makes can have a BIG impact.
(BTW...If I could get this thing to accept a PDF file I'd make it available on right here.)