1.Purchase date (month/year)

2.Describe the environment in which the product is used (e.g., high school, adult rehabilitation program, U.S. Department of Veterans Affair--VR&E, etc.).

3.Describe the person who facilitates the use of the product (e.g., classroom teacher, TVI, COMS, O&M instructor, rehabilitation specialist, etc.).

4.Describe the person who uses the product (e.g., 14-year-old with low vision and cerebral palsy, adult with light perception and vestibular disorder, senior with macular degeneration and diabetic neuropathy, etc.).

5.Rate the product's value.

5 = high

4

3

2

1 = low

5 = high

4

3

2

1 = low

6.Comment on the product's value.

7.Rate the product's design.

5 = high

4

3

2

1 = low

5 = high

4

3

2

1 = low

8.Comment on the design.

9.Provide any tips for using the product.

10.Provide general comments on the product.