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Graphiti Field Evaluator Application
1.
Address
Name
Job Title/Occupation
School/Agency
School/Agency
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
2.
Your ethnicity/race
Hispanic of any race
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Two or more races
3.
How many years of experience do you have in the field of education and/or blindness/accessible technology?
0-5
6-10
11-15
16-20
21+
4.
What is your preferred reading medium?
Print
Large Print
Braille
Electronic
5.
Which categories of students or clients/consumers do you work with? Check all that apply.
Elementary School
Middle School
High School
Adults
6.
How many students or clients/consumers do you have that will be able to use the Graphiti?
7.
What is the instructional setting of your students or clients/consumers? Check all that apply.
Residential School
Itinerant – Public School
Other – please list
8.
I agree to sign a Nondisclosure Agreement with Orbit Research.
Yes
No
Current Progress,
0 of 8 answered