1.Purchase date (month/year)

2.In what setting (e.g., early childhood program, elementary school, home, adult day program, etc.) is the product being used?

3.Describe the person facilitating the use of the product (e.g., classroom teacher, TVI, OT, PT, parent, etc.).

4.Describe the learner using the product (e.g., 3-year-old with low vision and CP, 12-year-old with deafblindness, adult with light perception and autism, 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 product's design.

9.What is the learner's favorite activity when using the product?

10.Provide any tips for using the product.

11.Provide general comments on the product.