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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. Title/Role

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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 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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* 12. Please describe your experience using the headset and going through each training scenario:

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* 13. Were there any scenarios in the training that you found more useful? Were there any scenarios in the training that you thought were challenging?

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* 14. Which of the following best describes how the headset was used?

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* 15. What insights from the training will you implement into your personal practice? What insights from the training will affect your personal relationships with others?

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* 16. What other types of trainings with virtual reality would you like to see?

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* 17. If you experienced any malfunctions or difficulties in setting up the headset, or if there were any parts of the set-up that you found confusing, please describe these issues below:

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* 18. Going forward, what can we do to improve the virtual reality experience?

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