Assistive Technology of Ohio Customer Survey (2018-2019)

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What is your name? *

Which device did you borrow? *

What was the purpose of the device? *

Please indicate the reason which best applies

To assist in decision making (device trial or evaluation)

To serve as a loaner device during repair or while waiting for funding

To provide an accommodation on a short-term basis

Other:

Required

Which category best describes the person who borrowed the device? *

Please indicate the description which best applies

Individual with disabilities

Family members, guardians, and authorized representatives

Representatives of education

Representatives of employment

Representatives of health, allied health, and rehabilitation

Representatives of community living

Representatives of Technology

Other:

Required

Which description of need best applies to your situation? *

Please indicate the description which best applies

A.T. primarily needed for education

A.T. primarily needed for employment

A.T. primarily needed for community living

A.T. primarily needed for I.T. / telecommunications

Required

Which of the following best describes your decision regarding the device? *

I decided the device / equipment will meet my needs

I decided that the device / equipment will not meet my needs

I have not made a decision

Required

How would you rate your level of customer satisfaction? *

Please indicate the description which best applies

Please let us know how this service has helped you by telling us about your specific situation. (optional)

Let us know how this device will impact your life. (begin typing in box below)

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