Assistive Technology of Ohio Device Demonstration Survey
Please help us improve our services by filling out the following (very brief) survey about our Device Demonstrations... Thank you!
* Required
What is your name? (optional)
Last, first
This is a required question
When did you undergo a device demonstration?
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day/month/year
This is a required question
Where did you undergo a device demonstration
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Please describe (at home, at Goodwill Rehabilitation Center, etc.)
This is a required question
Which area does the device demonstrated assist with?
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Please select the answer that best applies...
Vision
Hearing
Speech communication
Learning, cognition and developmental
Mobility, seating and positioning
Daily living
Environmental adaptations
Vehicle modifications and transportation
Computers and related
Recreation, sports and leisure
Other:
This is a required question
Which category best describes you, the person that underwent the device demonstration?
*
Please select the answer that best applies...
Individual with disability
Family member, guardian or authorized representatives
Representative of education
Representative of employment
Representative of health, allied health, and rehabilitation
Representative of community living
Representative of technology
Other:
This is a required question
Which answer best applies for your situation?
*
Please select one
The A.T. is primarily needed for education
The A.T. is primarily needed for employment
The A.T. is primarily needed for community living
The A.T. is primarily needed for I.T. / telecommunications
This is a required question
Please let us know which response best describes your situation...
*
Please select one
I have decided the device will meet my needs
I have decided the device will not meet my needs
I have not made a decision
This is a required question
Please let us know your level of satisfaction with our device demonstration...
*
Please select one
Highly satisfied
Satisfied
Satisfied somewhat
Not at all satisfied
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