1. Alaska Dual Sensory Impairment (DSI) Questionnaire 2012-2013

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* 1. I am a(n)

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* 2. Please indicate specific DSI supports you are interested in receiving from AK DSI Services. Check all that apply!

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* 3. Your preferred mode of receiving support is:

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* 4. Your preferred length of student service report?

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* 5. Please rate the usefulness of products and services provided:

USING YOUR IDEAS!
Please answer the following questions so we may design supports to meet your needs!

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* 6. What is your highest program need?

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* 7. What AK DSI service has worked best for you?

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* 8. What AK DSI service does not work for you?

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* 9. How can we improve AK DSI services?

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* 10. Other Comments/Feedback

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* 11. Communication: Please list below names and e-mail addresses of students, parents, teachers, paraprofessionals, and others you want included on the DSI mailing list.

Thank you for taking the time to complete this questionnaire!
Your time is sincerely appreciated!

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