Evaluation Form We sincerely appreciate your valuable time to provide us with feedback. Your responses help us to improve. Provide the name and date of birth of the person who received the technology equipment: Name First Last Date of Birth: Provide the names of the parents or caregiver (if applicable): Name: First Last Name: First Last Developmental Disability of the recipient of the equipment:What Assistive Technology equipment did you receive from this program?What can you do now that you could not accomplish before receiving the Assistive Technology Equipment from The Arc of Illinois?Check all that apply. Help with communication Help me be more independent Help me arrange for the bus Help me with a job Other Specify Other:How has this program enabled you to make a change in your life? Do you feel you have a better quality of life with the use of this equipment?Was this device needed for communication, visual supports, leisure or other?In which of the following areas did the technology device help you?Check all that apply. Employment Housing Recreation Community Supports Child Care Early Intervention Transportation Self-Determination Communication Independence Did you receive any other assistance to receive this equipment? Yes No Please explain.How did you learn about The Arc of Illinois Assistive Technology Program?Please select one. Another self-advocate/parent Your local Service Provider Newsletter News article Website Other Describe Other:How would you rate the Assistive Technology Program overall?Please select one. Very Satisfied Satisfied Somewhat Satisfied Dissatisfied Very Dissatisfied This iframe contains the logic required to handle Ajax powered Gravity Forms.