One Book Traveling Trunks
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1.
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1
. Name of Person Completing Survey
Name of Person Completing Survey
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2
. Name of Facility
Name of Facility
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3
. Address of Facility
Address of Facility
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4
. Phone Number of Facility
Phone Number of Facility
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5
. Email of Facility
Email of Facility
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6
. Type of Facility
Type of Facility
Public Library
Childcare Facility
Head Start Program
Other
Other (please specify)
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7
. County
County
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8
. What Traveling Trunk did you use
What Traveling Trunk did you use
A Splendid Friend, Indeed
If You Were a Penguin
Inside Mouse, Outside Mouse
Stop Snoring Bernard
Up, Down and Around
What a Treasure!
Whose Shoes
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9
. Number of times the Trunk was used
Number of times the Trunk was used
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10
. Number of children you used the Trunk with
Number of children you used the Trunk with
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11
. Please list the number of chidren in each age group you used the Trunk with.
Please list the number of chidren in each age group you used the Trunk with.
birth to 2 year olds
3 and 4 year olds
5 and 6 year olds
7 to 10 years old
older than 10
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12
. Did you use the activity guide?
Did you use the activity guide?
yes
no
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13
. Please describe briefly how you used the Trunk
Please describe briefly how you used the Trunk
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14
. Please rate the Trunk for its usefulness to you
Please rate the Trunk for its usefulness to you
Very Useful
Somewhat Useful
Useful
Not Very Useful
Not Usefull at All
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15
. Would you recommend the Traveling Trunk to a co-worker or peer?
Would you recommend the Traveling Trunk to a co-worker or peer?
Yes
Maybe
No
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