OCALI Lending Library - Assistive Technology Evaluation

Question Title

* 1. Patron Name

Question Title

* 2. Email Address

Question Title

* 3. Are you a person with a disability?

Yes

Question Title

* 4. Are you a family member of a person with a disability?

Yes

Question Title

* 5. Title/Role

Question Title

* 6. Device or Kit Name

Question Title

* 7. List all of the devices/items used within the kit:

Question Title

* 8. Accession Number

Refer to the email you received regarding taking the survey to find the accession number of item borrowed. You can also look for the eight digit number associated with the item on top or side of the container that the items were packaged in.

Question Title

* 9. Date Requested

Please enter the date you requested the item below:

Date

Question Title

* 10. Date Received

Please enter the date you received the requested item below:

Date

Question Title

* 11. County

Question Title

* 12. Zip Code

Question Title

* 13. School District or Organization

If you work for a school, please enter the name of the district that your school belongs to. If you do not work for a school, please simply enter the name of the organization that you work for.

Question Title

* 14. How was this device/kit used?

Individual or Student evaluation/trial

Professional development/training to others

Other (please describe)

Question Title

* 15. If the device/kit was used for professional development/training to others, please enter the number of participants below. Otherwise, leave this question blank.

Educational Staff

Parents

University Students

Other Participants

Question Title

* 16. If used for evaluation, what disability category? (check all that apply)

Autism spectrum disorder (ASD)

Deafness

Deaf-blindness

Emotional disturbance

Hearing impairment

Intellectual disability

Multiple disabilities

Other health impairment

Orthopedic impairment

Specific learning disability (SLD)

Speech or language impairment

Traumatic brain injury

Visual impairment, including blindness

Question Title

* 17. How will this device be used to enable the student to access the general curriculum? (check all that apply)

Access to Curricular Materials: Writing, Reading, Math, Social Studies, Science

Augmentative Communication

Computer Access/Mobile Device Access

Functional Living Skills

General Activities/School Activities

Organization

Sensory Needs

Other (please describe)

Question Title

* 18. As a result of this evaluation/trial, the following has been determined:

This device/kit is appropriate to meet the needs of the student/individual.

This device/kit is appropriate to meet the needs of the trainer given their specific audience.

This device/kit is not an effective tool for the student/individual or training audience; other devices/kits/systems will be explored.

Question Title

* 19. If this device/kit was used for professional development or training, please indicate what participants increased their understanding of: (check all that apply)

The operation of this device/kit

How this device/kit may increase the student/individual’s achievement in areas of need

OCALI Lending Library - Assistive Technology Evaluation

Question Title

* 1. Patron Name

Question Title

* 2. Email Address

Question Title

* 3. Are you a person with a disability?

Question Title

* 4. Are you a family member of a person with a disability?

Question Title

* 5. Title/Role

Question Title

* 6. Device or Kit Name

Question Title

* 7. List all of the devices/items used within the kit:

Question Title

* 8. Accession NumberRefer to the email you received regarding taking the survey to find the accession number of item borrowed. You can also look for the eight digit number associated with the item on top or side of the container that the items were packaged in.

Question Title

* 9. Date Requested

Question Title

* 10. Date Received

Question Title

* 11. County

Question Title

* 12. Zip Code

Question Title

* 13. School District or OrganizationIf you work for a school, please enter the name of the district that your school belongs to. If you do not work for a school, please simply enter the name of the organization that you work for.

Question Title

* 14. How was this device/kit used?

Question Title

* 15. If the device/kit was used for professional development/training to others, please enter the number of participants below. Otherwise, leave this question blank.

Question Title

* 16. If used for evaluation, what disability category? (check all that apply)

Question Title

* 17. How will this device be used to enable the student to access the general curriculum? (check all that apply)

Question Title

* 18. As a result of this evaluation/trial, the following has been determined:

Question Title

* 19. If this device/kit was used for professional development or training, please indicate what participants increased their understanding of: (check all that apply)

Question Title

* 20. Other comments or technical issues that need our attention (repair, missing components, items not working):

* 8. Accession Number

Refer to the email you received regarding taking the survey to find the accession number of item borrowed. You can also look for the eight digit number associated with the item on top or side of the container that the items were packaged in.

* 13. School District or Organization

If you work for a school, please enter the name of the district that your school belongs to. If you do not work for a school, please simply enter the name of the organization that you work for.