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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?

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

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* 6. Device or Kit Name

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

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* 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 six digit number associated with the item on top or side of the container that the items were packaged in.

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* 9. Date Requested

Date

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* 10. Date Received

Date

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* 12. Zip Code

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* 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.

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* 14. How was this device/kit used?

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* 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.

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

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

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

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

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

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