Assistive Technology of Ohio Customer Survey
RequiredRequired Question(s)
Required 1.

Name of Borrower 


50 characters left.
Required 2.
What device(s) did you borrow?

350 characters left.
Required 3.
What was the purpose of the device loan?
To assist in decision-making (device or trial evaluation)
To serve as a loaner device during repair or while awaiting funding
To provide a short-term accommodation
Required 4.
Which category best describes the person who borrowed the device? 
Individual with a disability
Family member, guardian or legal representative
Representative of Education
Representative of Employment
Representative of Health, Allied Health or Rehabilitation
Representative of Community Living
Representative of Technology
Required 5.

Which description of need best applies in your situation?

Technology primarily needed for Education
Technology primarily needed for Work
Technology Primarily needed for Community Living
Required 6.

Which of the following best describes your situation?

I decided that the device/equipment will meet my needs
I decided the device/equipment will not meet my needs
I have not made a decision
Required 7.

How would you rate your level of customer satisfaction with the service (not the device)?

Not at all Satisfied
Somewhat Satisfied
Highly Satisfied

Please let us know how this service helped you by telling us about your specific situation (optional) or let us know how this service has impacted your or the assistive technology user's life.


350 characters left.