Question Title

* 1. Patron Name

Question Title

* 2. Email Address

Question Title

* 3. Are you a person with a disability?

Question Title

* 4. Are you a family member of a person with a disability?

Question Title

* 5. Title/Role

Question Title

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

Question Title

* 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.

Question Title

* 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.

Question Title

* 9. Early Childhood Program Type

Question Title

* 10. Early Childhood Program Name

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

Question Title

* 11. Material or Kit Name

Question Title

* 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.

Question Title

* 13. Date Requested

Date

Question Title

* 14. Date Received

Date

Question Title

* 15. County

Question Title

* 16. Zip Code

Question Title

* 17. How was the material or kit used?

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

* 21. How well did the material/tool work?

Question Title

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

Question Title

* 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?

Question Title

* 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?

Question Title

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

T