Assistive Technology of Ohio Device Demonstration Survey

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Please help us improve our services by filling out the following (very brief) survey about our Device Demonstrations... Thank you!

What is your name? (optional)

Last, first

When did you undergo a device demonstration? *

day/month/year

Where did you undergo a device demonstration *

Please describe (at home, at Goodwill Rehabilitation Center, etc.)

Which area does the device demonstrated assist with? *

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:

Required

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:

Required

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

Required

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

Required

Please let us know your level of satisfaction with our device demonstration... *

Please select one

Submit

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