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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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* 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 six 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

Date

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* 8. Date Received

Date

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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:

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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):

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