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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. What grade level(s) do you teach? (please select all that apply)

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7. If one of the options you selected above was "Preschool/Pre-Kindergarten," please select which developmental domains you are interested in using the curriculum kit for (please select all that apply):

Please skip this question if you did not select "Preschool/Pre-Kindergarten" in the question above.

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8. What subject(s) do you teach? (please select all that apply)

If the grade level you selected in question 6 was "Preschool/Pre-Kindergarten," please skip this question.

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9. Early Childhood Program Type

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10. Early Childhood Program Name

Please enter the specific name of the program that you work for.

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11. Material or Kit Name

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12. 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 eight digit number associated with the item on top or side of the container that the items were packaged in.

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13. Date Requested

Date

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14. Date Received

Date

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15. County

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16. Zip Code

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17. How was the material or kit used?

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18. If you indicated above that the tool was used for professional development/training to others, please enter the number of participants below. Otherwise, leave this question blank.

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19. If used for evaluation, what disability category? (check all that apply)

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20. Why did you request the material/equipment? What did you use it for?

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21. How well did the material/tool work?

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22. How satisfied were you with this material/tool addressing your needs?

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23. On a scale of one through ten, in which one represents no success and ten represents absolute success, to what degree was this material/tool successful in helping a child/children engage in the activity?

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24. On a scale of one through ten, in which one represents no increase in independence and ten represents a massive increase in independence, to what degree did this material/tool increase a child/children's independence in an activity?

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

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