AT Device Assessment

This survey is to assess the need for assistive devices statewide after Hurricane Irma. If you have any Assistive Devices in need of repair or replacement after the storm, please fill out this short survey.

Contact Information

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* 1. Contact Information

Were you in the last 2 years or are you currently a Vocational Rehabilitation Customer?

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* 2. Were you in the last 2 years or are you currently a Vocational Rehabilitation Customer?

Were you in the last 2 years or are you currently a Division of Blind Services Customer?

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* 3. Were you in the last 2 years or are you currently a Division of Blind Services Customer?

Size of Item (If Applicable)

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* 5. Size of Item (If Applicable)

Quantity of Items

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* 6. Quantity of Items

Specific Information Regarding Request

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* 7. Specific Information Regarding Request

Do you have any Used, Working Assistive Technology Equipment you would like to donate? If so, please describe below.

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* 8. Do you have any Used, Working Assistive Technology Equipment you would like to donate? If so, please describe below.

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