O & M for Wheelchair Users
Consumer Feedback Survey

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* 1. Purchase date (month/year)

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* 2. Describe the environment in which the product is used (e.g., high school, adult rehabilitation program, U.S. Department of Veterans Affair--VR&E, etc.).

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* 3. Describe the person who facilitates the use of the product (e.g., classroom teacher, TVI, COMS, O&M instructor, rehabilitation specialist, etc.).

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* 4. Describe the person who uses the product (e.g., 14-year-old with low vision and cerebral palsy, adult with light perception and vestibular disorder, senior with macular degeneration and diabetic neuropathy, etc.).

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* 5. Rate the product's value.

5 = high

4

3

2

1 = low

5 = high

4

3

2

1 = low

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* 6. Comment on the product's value.

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* 7. Rate the product's design.

5 = high

4

3

2

1 = low

5 = high

4

3

2

1 = low

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* 8. Comment on the design.

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* 9. Provide any tips for using the product.

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* 10. Provide general comments on the product.