PATINS Lending Library Loan Evaluation

This short evaluation is required for EACH item borrowed from the PATINS Lending Library. The information you provide helps us offer better recommendations about equipment for future users and also to justify the time, effort and resources needed to maintain the lending library. Thank you.

RETURN SHIPPING
Return UPS Shipping Insurance is now at the discretion of the sender. Please return all borrowed items/devices to the site that they were shipped from to you.

Southwest PATINS Northwest PATINS
3711 Casey Road 2150 West 97th Place
Newburgh, IN 47630 Crown Point, IN 46307

Which PATINS site did you receive borrowed items? *

School Corporation & School/Agency Name *

Your answer

Item/Device Evaluation: Please fill out an evaluation for EACH item borrowed. *

Item/Device Name

Your answer

Please check ALL that apply *

First Time Borrower from PATINS

I borrowed to Improve access to the curriculum

I borrowed to Improve classroom participation

I borrowed to Improve computer access

Required

Student Age(s) *

Primary Disability(s) of Student(s) *

ASD - Autism

BLV - Blind/Low Vision

CD - Cognitive Disability

DHH - Deaf/Hard of Hearing

DB - Deaf/Blind

DD - Developmental Delay

ED - Emotional Disability

LSI - Language/Speech Impairment

MD - Multiple Disability

OHI - Other Health Impairment

OI - Orthopedic Impairment

SLD - Specific Learning Disability

TBI - Traumatic Brain Injury

No Documented Disability

Other:

Required

Was Borrowed Item appropriate for the student? *

Yes

Did the student's academic achievement improve as a result of using Borrowed Item? *

Yes

Did the student's behavior improve as a result of using Borrowed Item? *

Yes

Did the student's participation in general ed. increase as a result of using Borrowed Item? *

Yes

If there was improvement, please provide information regarding success.

If there was not, do you have any insights as to why it didn't?

Your answer

Please Check All That Apply: *

I have or will request that my school/district purchase this equipment/materials, or something similar, to use with the student.

I need purchasing information.

I am not requesting a purchase at this time.

Required

Rate Us! *

Please rate your satisfaction with the service that the PATINS Site provided.

Poor

OK, But Needs Improvement

Just Good Enough

Great

Excellent

Please feel free to share any additional comments:

Your answer

Would you or your staff/colleagues like any FREE training or consultation that PATINS can provide for you?

If so, please provide specific training needs and contact information. We will be happy to assist you.

Your answer

We sometimes use borrower's comments or feedback for our website to provide personal experiences of devices/equipment use and our services for other educators. May we use yours? *

Yes, I don't mind.

I'd rather not.

Do you have another item/device that you need to evaluate? *

Yes

First and Last Name *

Your answer

Your Email: *

Your answer

Option 1

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