OCALI Lending Library - Assessment Evaluation

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* 1. Patron Name

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* 2. Email Address

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* 3. Are you a person with a disability?

Yes

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

Yes

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* 5. Title/Role

Speech and Language Therapist/Pathologist

Occupational Therapist

Physical Therapist

Intervention Specialist/Special Education Teacher/Educational Diagnostician

Psychologist

Social Worker

Other (please specify)

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* 6. Assessment Tool Name

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* 7. 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.

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* 8. Date Requested

Please enter the date you requested the item below:

Date

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* 9. Date Received

Please enter the date you received the requested item below:

Date

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* 10. County

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* 11. Zip Code

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* 12. 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.

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* 13. How was the assessment tool used?

Preview or reference for district purchase

Individual or Student evaluation/trial

Professional development/training to others

Other (please describe)

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* 14. If you indicated above that the tool was used for professional development/training to others, please enter the number of participants below. Otherwise, leave this question blank.

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* 15. 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

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* 16. As a result of the access to this assessment tool, the following has been determined: (check all that apply)

This assessment tool is appropriate to meet the needs of the evaluator and the student.

The district will explore the acquisition of this assessment tool.

Further training on the assessment tool is needed.

Further exploration of other assessment tools is needed.

OCALI Lending Library - Assessment 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?

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* 5. Title/Role

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* 6. Assessment Tool Name

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* 7. 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.

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* 8. Date Requested

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* 9. Date Received

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* 10. County

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* 11. Zip Code

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* 12. 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.

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* 13. How was the assessment tool used?

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* 14. If you indicated above that the tool was used for professional development/training to others, please enter the number of participants below. Otherwise, leave this question blank.

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

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* 16. As a result of the access to this assessment tool, the following has been determined: (check all that apply)

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

* 7. 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.

* 12. 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.