OCALI Lending Library - Assessment Evaluation Question Title * 1. Patron Name Question Title * 2. Email Address Question Title * 3. Are you a person with a disability? Yes No Question Title * 4. Are you a family member of a person with a disability? Yes No Question Title * 5. Title/Role Speech and Language Therapist/Pathologist Occupational Therapist Physical Therapist Intervention Specialist/Special Education Teacher/Educational Diagnostician Psychologist Social Worker Other (please specify) Question Title * 6. Assessment Tool Name Question Title * 7. Accession NumberRefer 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. Question Title * 8. Date Requested Please enter the date you requested the item below: Date Question Title * 9. Date Received Please enter the date you received the requested item below: Date Question Title * 10. County Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot Question Title * 11. Zip Code Question Title * 12. School District or OrganizationIf 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. Question Title * 13. How was the assessment tool used? Preview or reference for district purchase Individual or Student evaluation/trial Professional development/training to others Other (please describe) Question Title * 14. 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. Question Title * 15. If used for evaluation, what disability category? (check all that apply) Autism spectrum disorder (ASD) Deafness Deaf-blindness Emotional disturbance Hearing impairment Intellectual disability Multiple disabilities Other health impairment Orthopedic impairment Specific learning disability (SLD) Speech or language impairment Traumatic brain injury Visual impairment, including blindness Question Title * 16. As a result of the access to this assessment tool, the following has been determined: (check all that apply) This assessment tool is appropriate to meet the needs of the evaluator and the student. The district will explore the acquisition of this assessment tool. Further training on the assessment tool is needed. Further exploration of other assessment tools is needed. Question Title * 17. Other comments or technical issues that need our attention (repair, missing components, items not working): Done