OCALI Lending Library - FM System Equipment 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. Name of FM System Used

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* 6. 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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* 7. Date Requested

Please enter the date you requested the item below:

Date

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* 8. Date Received

Please enter the date you received the requested item below:

Date

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* 9. County

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* 10. Zip Code

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* 11. School District/Other Agency Served with this FM System

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.

Educational Audiologist

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* 12. Please enter the following information regarding the team's educational audiologist:

Name

Employing Agency

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* 13. Student evaluation/trial is part of a team decision-making process. If so, what is the student's profile?

Deaf as defined by the State of Ohio Operating Standards

Hearing Impaired as defined by the State of Ohio Operating Standards

Auditory Processing Disorder

Other (please specify)

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* 14. What Assistive Technology is the student currently using? (check all that apply)

Unilateral Hearing Aid

Bilateral Hearing Aids

Unilateral Cochlear Implant

Bilateral Cochlear Implants

Bone Anchored Implanted Device

Other (please specify)

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* 15. As a result of access to this FM system, the following has been determined: (check all that apply)

This system met the needs of the student.

The team will explore the acquisition of this type of technology.

Further exploration of technology is needed.

OCALI Lending Library - FM System Equipment 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. Name of FM System Used

Question Title

* 6. 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

* 7. Date Requested

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* 8. Date Received

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* 9. County

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* 10. Zip Code

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* 11. School District/Other Agency Served with this FM SystemIf 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

* 12. Please enter the following information regarding the team's educational audiologist:

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* 13. Student evaluation/trial is part of a team decision-making process. If so, what is the student's profile?

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* 14. What Assistive Technology is the student currently using? (check all that apply)

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* 15. As a result of access to this FM system, the following has been determined: (check all that apply)

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

* 6. 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.

* 11. School District/Other Agency Served with this FM System

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.