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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. Are you a professional working with a person with a disability?

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* 7. 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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* 8. Date Requested

Date

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* 9. Date Received

Date

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* 11. Zip Code

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* 12. School District or Organization

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.

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* 13. What resource(s) have you used in your professional practice?

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* 14. How have you used the Resource Gallery of Interventions? Please select all that apply:

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* 15. Tell us how the interventions and information from the Resource Gallery made an impact on your practice, on the support you provided to families, and on the families:

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* 16. What other strategies would you recommend to be included in the Resource Gallery?

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* 17. Which best describes how you found out about this resource?

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

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